La. Medicaid Services Manual ch. 24 (Hospice) § 24.5

A hospice provider must be Medicare certified in order to qualify for enrollment as a Louisiana

Medicaid hospice provider. The hospice provider must be enrolled prior to billing for any services

provided to Medicaid beneficiaries.

Licensure

Except to the extent required by the licensing standards for hospice as defined in the Louisiana

Administrative Code (LAC) 48:I.Chapter 82, §8205.A.1, it shall be unlawful to operate or maintain

a hospice program without first obtaining a license from the Louisiana Department of Health

(LDH). LDH is the only licensing authority for hospice providers in the state of Louisiana.

Provider Responsibilities

The hospice provider must ensure employees providing hospice services have all licensure,

certification or registration requirements in accordance to applicable federal and/or state laws.

Inpatient Care Cap

A cap is placed on the number of allowable inpatient hospice days that can be provided by a

hospice facility to fee-for-service beneficiaries during the 12 -month period beginning November

1st of each year to October 31 st of the following year. This cap is calculated as 20 percent of the

total number of hospice days provided by the facility.

A review of the total number of hospice days provided by a facility is performed annually. The

rate for each day in excess of the allo wable inpatient care cap is adjusted to pay the routine care

amount. The difference between the two amounts shall be remitted to LDH.

Interdisciplinary Group

Additionally, the hospice provider must designate an interdisciplinary team (IDT ) composed of

qualified medical professionals and social support staff from all core services, with expertise in

meeting the special needs of hospice beneficiaries and their families. The IDT must consist of the

following individuals:

1. Physician;

2. Registered Nurse (RN);

3. Social Worker; and

4. Pastoral or other counsel.

NOTE: Nurse practitioners (NPs) may not serve as medical director or as the physician member

of the IDT.

Plan of Care

A written plan of care (POC) must be established before services are provided and must be

maintained for each beneficiary admitted to a hospice program in accordance with the provisions

set forth in the Licensing Standards for Hospices (LAC 48:I.Chapter 82). The initial POC must be

established on the same day as the assessment if the day of assessment is to be a covered day of

hospice. The date of the POC should be the date it is first established. The care provided to a

beneficiary must be consistent with the plan and be reasonable and necessary for the palliation or

management of the terminal illness as well as all related conditions. In establishing the initial POC,

the member of the basic IDT who assesses the patient’s needs must meet or call at least one other

group member (nurse, physician, or medical social worker or counselor) before writing the initial

POC. At least one of the persons involved in developing the initial POC must be a nurse or

physician. The POC is signed by the attending physician or an appropriate member of the IDT.

The POC must encompass plans on access to emergency care and address the condition of the

beneficiary as a whole. All co-morbidities must be included even those not related to the terminal

illness. In addition, the POC must meet general medical needs of beneficiaries to the extent that

these needs are not being met by the attending physician. This information is being required to

assess the beneficiary for complications and risk factors that would affect care planning ( i.e.,

access to emergency care). Providers may not be responsible for providing care for the unrelated

co-morbidities.

There is no official hospice POC form. Each hospice provider should develop a form which

includes the required information and best meets its needs.

Physician Certification and Narrative

The hospice provider must obtain written certification of terminal illness (CTI) via the Bureau of

Health Services Financing ( BHSF) Form Hospice - CTI. The CTI must specify that the

beneficiary’s prognosis is for a life expectancy of six months or less if the terminal illness runs its

normal course. The CTI must be based on the physician’s clinical judgment regarding the normal

course of the individual’s illness and must include the signatures of the physicians. A copy of this

CTI must be on file in the beneficiary’s clinical record.

Clinical information and other documentation that support the medical prognosis must accompany

the CTI and must be filed in the medical record with a written certification. In addition, the

attending physician must include a brief narrative explanation of the clinical findings that supports

a life expectancy of six months or less. This may be done as an addendum to the CTI and

recertification forms if additional space is needed. The physician must also sign and date

immediately following the narrative in th e addendum. The physician must print and sign their

name. The narrative must include a statement under the physician signature attesting that by

signing, the physician confirms that they composed the narrative based on their review of the

beneficiary’s medical record or, if applicable, their examination of the patient. The narrative must

reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard

language used for all patients. Submit this narrative along with the signed CTI form to the Hospice

Prior Authorization Unit (PAU). A copy of this certification must also be on file in the

beneficiary’s clinical record.

The narrative associated with the third benefit period recertification and every subsequent

recertification must include an explanation of why the clinical findings of the face-to-face

encounter support a life expectancy of six months or less.

Nurse Practitioners as Attending Physician

A NP is defined as a RN who is permitted to perform such services as legally authorized to perform

(in the state in which the services are performed) in accordance with state law (or state regulatory

mechanism provided by state law) and who meets training, education and experience requirements

described in 42 Code of Federal Regulations (CFR) 410.75.

If a beneficiary does not have an attending physician or a NP who has provided primary care prior

to or at the time of the terminal diagnosis, the beneficiary may choose to be served by either a

physician or a NP who is employed by the hospice provider. The beneficiary must be provided

with a choice of a physician or a NP. The attending physician or NP must be identified on the

notice of election (NOE), or on an addendum to the NOE, during the election of hospice services.

(See Section 24.2 – Election of Hospice Care of this manual chapter).

Services provided by a NP that are medical in nature must be reasonable and necessary, be included

in the POC and must be services that, in the absence of a NP, would be performed by a physician.

If the services performed by a NP are such that a RN could perform them in the absence of a

physician, they are not considered attending physician services and are not separately billable.

Services that are duplicative of what the hospice nurse would provide are not separately billable.

NPs cannot certify a terminal diagnosis or the prognosis of six months or less, if the illness or

disease runs it normal course, or re-certify terminal diagnosis or prognosis. In the event that a

beneficiary’s attending physician is a NP, the hospice medical director and another physician

designee must certify or re-certify the terminal illness. When a NP performs the encounter, the

attestation must state that the clinical findings of that visit were provided to the certifying

physician, for use in determining whether the patient continues to have a life expectancy of six

months or less, should the illness run its normal course. Regulations require the narrative to be

composed by the certifying physician only.

Certification of Terminal Illness

The hospice provider must obtain written certification of terminal illness (BHSF Form Hospice -

CTI) for each of the election periods, even if a single election continues in effect for two or more

periods. Written certifications may be completed two weeks before the beginning of each election

period. See Appendix B for detailed information on completing the BHSF Form Hospice - CTI.

Certification of Initial Period

The hospice provider must obtain BHSF Form Hospice - CTI no later than two calendar days after

hospice care is initiated. If written certification is not obtained within two calendar days, verbal

verification from the physician must be received by an IDT member and the verbal verification

section on the form must be completed and submitted to BHSF within two calendar days following

the initiation of hospice care. The c linical information may be provided verbally, and must be

documented in the medical record and included as part of the hospice provider’s eligibility

assessment. Written certification must be obtained no later than eight calendar days after care is

initiated. If the NOE (see Appendix A) physician’s narrative and CTI Forms are not received

within 10 calendar days of the initiation of hospice care, the date of admission (election) will be

the date that BHSF receives the proper documentation.

NOTE: The 10 calendar day requirement is the same for Medicaid only beneficiaries as well as

dual eligible (Medicaid/Medicare) beneficiaries.

Verbal Certification

If verbal certification is made, the referral from the physician must be receive d by a member of

the hospice IDT. The entry of the verbal certification in the beneficiary’s clinical record must

include at a minimum the beneficiary’s name, attending physician’s name, terminal diagnosis,

prognosis, and the name, date and signature of the IDT member taking the referral. The diagnosis

code on the NOE and the diagnosis description on the CTI must match. The diagnosis description

must be notated on the CTI.

Hospice staff must make an appropriate entry in the beneficiary’s clinical record as soon as a verbal

certification is received and file written certifications in the clinical record.

Sources of Certification

For the initial 90 calendar day period, the hospice provider must obtain a completed certification

form from the following:

1. The beneficiary’s attending physician. The attending physician must be a doctor of

medicine or osteopathy and must be identified by the beneficiary, at the time of

election for hospice care, as having the most significant role in the determination

and delivery of the individual's medical care; and

2. The hospice’s medical director or a physician member of the hospice IDT.

The beneficiary shall not be required to relinquish their attending physician in order to receive

hospice benefits. If the attending physician wishes to relinquish care of the beneficiary to the

hospice’s medical director, the attending physician must:

1. Sign the BHSF Form Hospice - CTI; and

2. Submit a narrative statement indicating relinquishment of the care of the patient to

the hospice physician.

For all subsequent periods, the hospice provider must submit the completed CTI form to the PAU

within 10 calendar days prior to the last day of the current benefit period. The form must be signed

and dated by either the medical director or a physician member of the IDT.

Face-to-Face Encounters

Section 3131(b) of the Affordable Care Act of 2010 requires a hospice physician or NP to have a

face-to-face encounter with every hospice beneficiary to determine the continued eligibility of that

beneficiary prior to the beneficiary’s 180th day recertification and each subsequent recertification.

These required encounters are due no more than 30 calendar days prior to the recertification date.

LDH will align with the Centers for Medicare and Medicaid Services (CMS) regarding the face –

to–face requirement.

The regulation requires that the hospice physician or NP attest that the encounter occurred, and the

recertifying physician must include a narrative which describes how the clinical findings of the

encounter support the beneficiary’s terminal prognosis of six months or less. The attestation

language must be located directly above the physician or NP attestation signature and date line.

The physician or NP must sign and date the form. The statement must include the date of visit, the

requested period, signat ure of the physician or NP who made the visit along with his date of

signature. The physician must print and then sign their name. Visit notes are not a substitute for a

physician narrative, which is a brief explanation of the clinical findings that supports continuing

eligibility for the hospice benefit. Outside attending physicians are not allowed to perform the

face-to-face encounter. The hospice provider is responsible for either providing the encounter itself

or fo r arranging for the encounter. Please note volunteer physicians are considered hospice

employees. Hospice providers are supposed to provide physician services to their beneficiaries

when needed during a time of crisis.

If a beneficiary improves or stabilizes sufficiently over time while in hospice, such that they no

longer have a prognosis of six months or less from the most recent recertification evaluation or

definitive interim evaluation, that beneficiary should be considered for discharge from Medicaid

hospice services.

NOTE: In the event that a beneficiary is in the hospital or emergency room (ER), and a referral

is made to hospice, the physician attending to the beneficiary in the hospital or ER or the physician

referring the beneficiary to hospice services must sign the BHSF Form Hospice - CTI, if the

beneficiary does not have an attending physician.

BHSF Written Notice of Hospice Decision

The Hospice PAU notifies the hospice provider and the hospice beneficiary (or legal

representative) of the beneficiary’s approval or denial of hospice services in writing. It is the

Hospice provider’s responsibility to notify the nursing facility. The approval letter contains the

election date and the prior authorization (PA) requirements (if applicable). The denial letter gives

the reason(s) for the denial.

Disaster Operations

The provisions set forth in the Licensing Standards for Hospices (LAC 48: I. Chapter 82) state,

“The hospice provider shall have policy and procedures and a written plan for emergency

operations in case of disaster.” To ensure compliance, all providers should adhere to the following

procedure in the event a state emergency occurs where evacuations are required:

1. Transportation during an emergency evacuation of a nursing facility beneficiary

receiving hospice services is the responsibility of the nursing facility;

2. Hospice beneficiaries who receive hospice services in their home and are without

accessible transportation during an emergency evacuation will be directed to a

parish pick-up point; and

3. Transportation during an emergency evacuation of an in- patient hospice facility

beneficiary is the responsibility of the inpatient hospice facility.

It is the responsibility of the hospice provider to know the location of beneficiaries under

their care at all times.

PROGRAM INTEGRITY

To maintain the programmatic and fiscal integrity of the Medicaid program, the federal and state

governments have enacted laws, promulgated rules and regulations and policies concerning fraud

and abuse, and LDH has established policies concerning those laws, rul es, regulations and

procedures. It is the responsibility of the provider to become familiar with these laws and

regulations.

Non-compliance with the provider agreement may place the provider in a position of sanctions

being imposed which include, but are not limited to, denial or revocation of enrollment,

withholding of payments, exclusion from the program, recovery of overpayments and

administrative fines.

Providers, beneficiaries and others may also be subject to criminal prosecution, civil action and/or

administrative actions if they violate laws, rules, regulations or policies applicable to the Medicaid

program.

Providers should refer to the Medicaid Services Manual, Chapter 1 General Information and

Administration for a full description of administrative sanctions.

NOTE: The provider should also refer to the laws and regulations related to sanctions for each

program of enrollment and should review LAC 50:I. Chapters 41 and Subpart E.