MO HealthNet Hospice Provider Manual § 2.17

MO HealthNet participants who elect the hospice benefit do not automatically forfeit their right to receive medical services such as Home and Community-Based Waiver services; however, the DSDS case manager or the Division of Community and Public Health, AIDS Waiver contract service coordinator must develop a care plan in collaboration with the hospice provider to ensure services are not duplicative. Upon request, the hospice must provide a copy of the existing plan of care and the newly developed plan of care to the DSDS case manager or Division of Community and Public Health contract service coordinator.

MHD conducts post-payment reviews of hospice services billed on the same dates as other home and community-based services (HCBS). The hospice provider maintains responsibility for nursing, home health aide, and homemaker services. The AIDS Waiver, Aged and Disabled Waiver (ADW), and Personal Care program may provide authorized services that are beyond the responsibility of the hospice so long as those services do not duplicate those which are the responsibility of the hospice. A hospice may not refuse to provide services on the basis that these services are available under other provisions of the plan or waiver, or because the hospice has inadequate staff to meet the needs of a particular participant.

Personal Care Services

MO HealthNet covers personal care services to persons at home or residing in a Residential Care Facility (RCF) or Assisted Living Facility (ALF), licensed by DHSS, DSDS. Personal care services consist of assistance with any ADL such as washing and grooming, toileting, dressing, meal service, socializing (companionship, hobbies, etc.), administration of medication, maintaining the cleanliness of the resident’s bed and room, and supervising and assisting in the use of DME and prescribed therapies (such as range of motion exercises and speech exercises). Household chores such as laundry incidental to the care of the participant and housecleaning in the area occupied by the participant is also covered under personal care. Personal care includes an advanced level of care for persons with altered body functions such as persons with ostomies, catheters, and persons with paraplegia or quadriplegia. The personal care services also include a visit by a nurse, up to weekly in frequency, for set up of self-administered medications, nail care for persons with medically contraindicating conditions, skin monitoring, and increased supervision for the advanced personal care participants.

Participants are considered eligible for personal care if they have needs that otherwise require NF care. Eligibility for services is determined by DSDS, or in the case of persons with Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV), by DHSS, Division of Community and Public Health. Personal care for children under 21 years of age is prior authorized by the BSHCN.

Personal care under the State Plan for persons 21 years of age and over is subject to a fiscal cap, predetermined annually based on average MO HealthNet NF costs. When the dollar cap is translated into a limit on services, the limit is approximately 80 to 120 hours of service per month. This is only approximate, as the actual number of hours in each case depends upon the individual’s need for basic or advanced personal care, and the frequency of nurse visits, if needed.

Refer to the Personal Care Provider Manual for more information.

Home and Community Based Waiver for Persons with AIDS/HIV

MO HealthNet participants with diagnoses of AIDS or HIV-related illnesses may be eligible for waiver services if they have needs that otherwise require NF care. A functional assessment is completed by contract service coordinators from the DHSS Division of Community and Public Health to determine eligibility for both State Plan personal care and waiver services. The following are the services available under the AIDS Waiver:

Private Duty Nursing: A participant may receive private duty nursing (PDN). PDN is the delivery of skilled nursing services (provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN)) within the home. Services include assessing HIV-related illnesses which may require medical intervention, reporting changes in the client’s condition to the physician, providing IV therapy, providing respiratory care including oxygen, changing dressings and caring for wounds, making referrals and teaching family members and others about the necessary care to maintain the client at home.

Waiver Personal Care: This service is in addition to the personal care available under the State Plan. The waiver personal care service provides assistance with ADL, however, it may continue beyond the limits of hours under the State Plan. Under the waiver, the aide may accompany the participant on visits to obtain medical care, whereas the aide under personal care cannot. Housekeeping chores necessary to maintain a safe and sanitary environment may not comprise more than one-third (1/3) of the time spent in the home.

Waiver Attendant Care: Waiver attendant care service is hands-on care, of both a supportive and health-related nature, specific to the needs of a medically stable, physically handicapped individual. Supportive services are those that substitute for the absence, loss, diminution, or impairment of a physical or cognitive function. Waiver attendant care includes skilled or nursing care. Housekeeping activities that are incidental to the performance of care may also be furnished as part of this activity.

Supplies: Limited to diapers, under pads, and gloves

Refer to the AIDS Waiver Provider Manual for more information.

Home and Community Based Waiver for the Aged and Disabled

The MO HealthNet Home and Community-based Waiver for the Aged and Disabled is a program available to MO HealthNet-eligible persons 63 years of age or older who otherwise require care in a NF or intermediate care home. Eligibility for ADW services is determined by case managers from DSDS.

Services under the ADW include:

Homemaker Services

Chore Services

Respite Care Services

Home Delivered Meals

Adult Day Care Services

Refer to the ADW Provider Manual for information on these services.

Authorization of Home and Community-Based Services for Persons who Elect Hospice

The following guideline is used by DHSS service coordinators and DSDS case managers when assessing initial or continued eligibility for waiver or personal care services for persons who have elected hospice.

Private Duty Nursing

The hospice benefit does not include PDN as defined by the AIDS Waiver, but does include nursing as defined in the list of covered hospice services in Section 2 of this manual. Hospice nursing care also includes a provision for continuous home care to be provided only during a period of crisis.

Under the hospice benefit, a minimum of eight (8) hours of nursing care per a 24-hour period beginning at midnight must be provided during a crisis period. A crisis is described as a period in which a participant requires continuous care, which is primarily nursing care, to achieve palliation or management of acute medical symptoms.

If PDN will be authorized under the AIDS Waiver, the service coordinator must plan the frequency and duration of the visits with the hospice provider to be sure the PDN service augments any service for which the hospice provider is responsible, either during a period of crisis or to maintain the participant on a routine basis.

PDN as defined by the AIDS Waiver does not include crisis intervention, whereas hospice nursing care as continuous home care is for crisis intervention. Refer to the AIDS Waiver Provider Manual for more information.

Supplies

The hospice reimbursement is structured to include any palliative care or service that is directly related to the terminal illness. Diapers, underpads, and gloves fit this definition and are the financial responsibility of the hospice. Supplies under the AIDS Waiver should never be authorized under the waiver for a participant who has elected hospice.

Refer to the AIDS Waiver Provider Manual for more information.

State Plan Personal Care, Waiver Personal Care, and Waiver Attendant Care

The hospice benefit includes home health aide and homemaker services. Home health aide and homemaker services are intended to meet personal care needs that are the result of the terminal illness. The hospice benefit, however, is not intended to provide a full-time caregiver. It is appropriate for a person who has elected hospice to also receive personal care and waiver attendant care.

The AIDS Waiver service coordinator or case manager needs to develop a personal care or waiver attendant care plan in collaboration with the hospice provider, who maintains primary responsibility for the participant, to ensure services are arranged appropriately in the best interest of the participant and to augment services which are the responsibility of the hospice.

Refer to the AIDS Waiver Provider Manual for more information.

Homemaker/Chore

While the homemaker/chore service is similar to the homemaker service, the hospice must provide to maintain a safe and sanitary environment in areas of the home used by the participant, the homemaker/chore service may go beyond the scope of the hospice in providing other housekeeping and maintenance services, both indoors and outdoors. For example, the Homemaker/Chore Program may include washing windows, vacuuming, dusting, cleaning kitchen appliances, bathroom fixtures, and ironing and mending of clothes.

The DSDS case manager must develop a homemaker/chore care plan in collaboration with the hospice provider, who maintains primary responsibility of the participant, to ensure services are arranged appropriately in the best interest of the participant and augment services that are the responsibility of the hospice.

Respite

The hospice may provide short-term inpatient respite care. ADW respite services are provided in the home, NF, or intermediate care home. The waiver respite service cannot be authorized during times when inpatient respite care under the hospice benefit is used. Respite care is appropriate for the hospice participant who has a caregiver (other than the hospice provider) who needs to be away from the home for periods of time (two (2) to 12-hour periods, for up to several days at a time). The DSDS case manager authorizes respite, when necessary, to augment hospice services.

Refer to the ADW Provider Manual for more information.

Institutional Respite Care

The hospice service may be provided in the home, NF, intermediate care home, or in a hospital, according to hospice regulations. State Plan personal care services or waiver services cannot be delivered and are not reimbursed while the participant is in a hospital or NF. The only exception to this is institutional respite care, which is authorized by the DSDS and may only be provided by a MO HealthNet-enrolled institutional respite provider, who must also be a licensed certified NF or intermediate care home.