PMA18243338 Hospice Care in a Nursing Facility, November 16, 2016
Hospice services are available to persons receiving MA who are dying. The person must receive services from a hospice that is certified by Medicare and enrolled in the MA Program. A list of certified, enrolled hospice providers is available on PROMISe.
The goal of hospice services is to make a dying individual as physically and emotionally comfortable as possible. The individual may receive hospice services at any of the following locations:
At home.
The home of a friend.
The home of a relative.
A hotel.
A personal care home.
A domiciliary care home.
An intermediate care facility.
A skilled Long Term Care (LTC) facility.
A hospital.
Hospice centers
NOTE: Hospitals, domiciliary care homes, intermediate care facilities and LTC facilities must be approved by the Office of Medical Assistance Programs to provide hospice services.
The following hospice facility codes are available in eCIS:
Hospice in a nursing home (facility code 37)
Hospice not received in a nursing home (facility code 39)
If an individual requesting hospice services is residing in an intermediate care or LTC facility, the CAO must apply MA LTC rules as it would for any other MA LTC applicant. This includes determining a person’s payment toward cost of care if the individual is receiving hospice service in an LTC facility.
42 USC 1396d(a) 55 Pa. Code § 1130.21
The hospice provider must let the CAO know within 7 days if the individual :
Chooses hospice care.
Cancels hospice care.
Moves to another hospice facility; or
Dies.
55 Pa. Code § 1130.51 55 Pa. Code § 1130.52
The hospice provider is responsible to complete the hospice service forms listed below. The CAO must narrate receipt of these forms in the case record and the forms must be scanned and attached to the record in the "MA Other" subcategory in order to include an Imaging Comment that identifies the form number.
Certification of Terminal Illness (MA 372) - The hospice provider has the form signed by the attending physician and hospice medical director every 60 days. An illness is considered terminal if the individual is expected to live six months or less. The CAO does not need a copy of this form; however,effective January 2015 the CAOs may begin to receive this form. If received, it must be scanned and attached to the record.
Election of Hospice Care (MA 373) - This form is signed by the individual to confirm that he or she wants to get hospice care. The hospice provider must give the CAO a copy of the form when an individual is applying for MA LTC or when a person moves to another hospice facility.
Change of Hospice Provider (MA 374) - If an individual chooses a new hospice provider, the new provider must get this form. The CAO must get a copy.
Revocation of Hospice Care (MA 375) - This form shows that the individual decided to cancel hospice services. The CAO must get a copy.
NOTE: If the individual cancels and then restarts hospice care with the same provider during the same certification period, a new certification of terminal illness (MA 372) is not needed until the beginning of the next certification period.
When the CAO receives the MA 373, the CAO will:
1. Make sure all needed information is on the form:
Check line 13 for a change of address. If there is an address change, take the right action.
Line 6 for the signature of the patient. If there is no patient signature, review line 9 for the name of the appointed legal representative. If no legal representative is listed, return the MA 373 to the provider and point out that the information is missing.
2. Check to see if the individual is receiving hospice care in an intermediate or LTC facility.
If the individual is receiving care in a place other than an intermediate or LTC care facility, see Section 438.71.
If the individual is receiving hospice care in an intermediate or LTC facility, see Section 438.72.
If the individual is receiving hospice services at a place other than an intermediate or LTC facility, the CAO will decide if the individual is already qualified for MA.
If the individual is a MA recipient, the CAO will:
1. Scan and attach the MA 373 to the record.
2. Narrate receipt of all hospice forms.
3. Change the individual's address in eCIS, to the address found in box 13 of the MA 373 if needed.
4. Enter facility code 39 (hospice not received in a nursing home) on the Facility Placement screen in eCIS.
If the individual is not a current MA recipient the CAO will:
1. Scan and attach the MA 373 to the record.
2. Narrate receipt of all hospice forms.
3. Determine the individual's eligibility for MA using current policy and procedures. Consider categories: PH, PA, PJ, or MG.
4. Enter facility code 39 (hospice not received in a nursing home) on the Facility Placement screen in eCIS.
Hospice services may be given by a hospice provider to an individual living in an intermediate or LTC facility. Services are provided under a special room and board plan.
If the individual receiving hospice in a facility is a current MA LTC recipient, the CAO will:
1. Scan and attach the hospice forms to the case record.
2. Narrate receipt of all hospice forms.
3. Enter the hospice provider information on the Provider screen in eCIS.
NOTE: DO NOT update the facility code to code 37 (hospice in a nursing home). You will be notified once system changes are implemented to allow facility code 37 to be entered.
4. Send a notice of eligibility to the hospice provider
NOTE: A system generated notice will not be generated if there is no change in category or cost of care. Send a copy of the most current eligibility notice to the hospice provider.
5. Keep a log of LTC cases receiving hospice in the LTC facility.
If the individual is applying for hospice in a facility, the CAO will:
1. Scan and attach the hospice forms to the case record.
2. Narrate receipt of all hospice forms.
3. Enter the hospice provider information on the Provider screen in eCIS.
4. Determine the individual's eligibility for MA LTC in a LTC facility category (PAN, PCN, PJN, PMN, PVN, TAN, TJN, TVN) using the guidelines found in Section 468.2, MA LTC Eligibility -Step 1.
5. Enter the appropriate LTC facility placement code indicating the individual is residing in either an intermediate care facility or LTC facility.
NOTE: DO NOT enter facility code 37 (hospice in a nursing home). You will be notified once system changes are implemented to allow facility code 37 to be entered.
Reminder: If an individual with an open hospice facility code 39 (hospice not received in a nursing home) enters a LTC facility, the facility code 39 must be end-dated the day before the admission to the LTC facility. The appropriate LTC facility placement code should be entered effective the date of admission.
6. Determine the individual's payment toward cost of care using the guidelines found in Section 468.3 Payment Toward the Cost of LTC Facility Services- Step 2 and Section 468.4 Determining Eligibility for LTC Facility Services.
7. Send a notice of eligibility to the individual, representative, hospice provider and LTC facility. if the individual is not eligible for a MA LTCpayment, tell the person that the hospice may not charge a rate which is more than the MA LTC rate.
8. Keep a log of LTC cases receiving hospice in the LTC facility .
An individual may change hospice providers once during the 60 day period set by the MA 372.
EXAMPLE: Mr. W received MA LTC hospice services from Hospice of PA for 40 days beginning on December 1. On January 9, the Hometown Hospice sent a copy of an MA 374 to the CAO to let the CAO know that Mr. W changed his hospice to Hometown. After Hometown Hospice gave services to Mr. W for 21 days, the CAO received an MA 374 on January 30 that says Mr. W decided to return to Hospice of PA.
Mr. W was able to make both changes, because each occurred in a separate 60 day certification period. If Mr. W wants to make another change, he must wait until April 1 (60 days from the last change).
When a provider change is made, the CAO must get a completed MA 374 from the new provider. The CAO will review the information to see whether any changes are needed and will scan and attach the form to the record.
If the individual moves from one hospice location to another, the new hospice provider will give the CAO an MA 373 within 7 calendar days. The CAO must scan and attach the MA 373 to the record.
When a change in the hospice address is received, the CAO will:
1. Change the address.
2. If the individual has moved out of an LTC facility, decide MA eligibility using the same rules for an individual who is not in an LTC facility.
3. If the individual has moved into a hospice located in an LTC facility, decide the individual’s payment toward the cost of care. See Section 438.72, Eligibility for Hospice in an Intermediate or LTC facility.
An individual may stop hospice service at any time for any reason. If the individual stops hospice care while in an LTC facility, the CAO will determine MA LTC eligibility for the required level of care.
If the individual decides to stop hospice care, the hospice provider will fill out and send the MA 375 to the CAO within 7 calendar days. The CAO must scan and attach the MA 375 to the record.
If the individual wants hospice care again, the hospice provider must complete an MA 373and send a copy to the CAO. The CAO must scan and attach the MA 373 to the record.
Updated November 16, 2016, Replacing May 27, 2015