MO HealthNet Hospice Provider Manual § 2.5

There are five (5) basic components involved in the MO HealthNet participant's enrollment in hospice, each described below. The hospice must retain all election documentation and furnish it to MHD or its representative upon request. For a chart of all applicable forms and when they are due, refer to Section 3 in this manual.

Physician Certification of Terminal Illness

The hospice provider must obtain the physician certification that an individual is terminally ill. The Physician Certification of Terminal Illness includes the statement that the individual’s medical prognosis is a life expectancy of six (6) months or less and must contain the physician’s signature(s) and be dated by the physician(s).

Certifications must be submitted timely for each hospice benefit period through the end of the election. A hospice benefit period consists of two initial 90-day benefit periods where participants received comprehensive hospice services. After the initial periods, participants can continue to receive care in 60-day increments, as long as they are recertified terminally ill by a physician. If the certification date(s) for the specific benefit period is not submitted to MO HealthNet the hospice claims will deny.

Anytime a patient leaves hospice, whether it is a revocation, discharge, or decertification, and then reelects hospice, it is considered a new election. For new elections, the hospice must provide an initial Physician Certification of Terminal Illness with signatures of both the attending physician and hospice medical director or physician member of the hospice’s interdisciplinary group. Claims deny for lack of two (2) signatures on the Physician Certification of Terminal Illness for the first period of an election.

Refer to Section 3 in this manual for more information on the Physician Certification of Terminal Illness.

Election Procedures

A Hospice Election Statement must be completed for each MO HealthNet hospice participant and for each participant eligible for both Medicare and MO HealthNet. Failure to complete all fields results in denial of hospice claims. An individual receiving hospice services as a private pay client who becomes eligible for MO HealthNet must sign a Hospice Election Statement, which must be submitted by the hospice to MHD as an attachment to the election statement under which hospice care was initiated. The participant's hospice election date for which services may be reimbursed by MHD is no earlier than the first date of MO HealthNet eligibility.

An election may also be filed by the participant who elects to receive hospice or by a representative of the participant, acting pursuant to State law. With respect to an individual granted conservatorship (guardian) or the power of attorney for the participant, State law determines the extent to which the individual may act on the participant’s behalf.

Completed Hospice Election Statements should be faxed to MHD at (573) 526-2041 or mailed to the following:

MO HealthNet Division

Hospice Unit

PO Box 6500

Jefferson City, MO 65102

Election Periods

An election to receive hospice care continues through the initial election period and through any subsequent benefit periods without a break in care as long as the individual remains in the care of the hospice, does not revoke the election, or is not decertified by a hospice physician or the individual’s attending physician.

The date the election is made effective is the date the participant or their representative signs the Hospice Election Statement. An individual may designate an effective date for the election by the date of signature or by designating any subsequent date; however, an individual may not designate an effective date for the election that is earlier than the date of the signature.

An individual who is eligible for both Medicare and MO HealthNet must elect and revoke the hospice benefit simultaneously under both programs. The Medicare hospice benefit covers all hospice services other than NF room and board. Refer to Dual Eligible Hospice Patients below.

MO HealthNet follows Medicare benefit periods. Participants who qualify may receive hospice care for two (2) 90-day benefit periods, followed by an unlimited number of 60-day periods while the individual remains in hospice care. However, anytime a patient leaves hospice, whether it is a revocation, discharge, or decertification, and then reelects hospice, it is considered a new election, beginning with an initial certification period of 90 days that requires the Physician Certification of Terminal Illness signed by both the attending physician and the hospice medical director or physician member of the hospice’s interdisciplinary group.

Nursing Facility or Intermediate Care Home Residence

For purposes of the MO HealthNet hospice benefit, a MO HealthNet certified NF or intermediate care home can be considered the residence of a participant. A participant residing either at home or in a NF or intermediate care home may elect the hospice benefit.

When the hospice provides care to an individual residing in a NF or intermediate care home, MHD can make reimbursement to the hospice, in addition to routine (or continuous) home care days, for the room and board provided by the NF or intermediate care home. For MHD to reimburse the hospice for room and board the following requirements must be met:

The hospice and the NF or intermediate care home must have a written agreement or contract

The hospice must notify MHD of the contract utilizing a Hospice-Nursing Facility (NF) Contract Update form

The hospice must reimburse the nursing home for room and board services

Waiver of Rights to Services

An individual must waive all rights to MO HealthNet services related to the treatment of the terminal condition and any related conditions for which hospice care was elected, or for services that are equivalent to hospice care, except for services that are provided by the following:

The designated hospice

Another hospice under arrangements made by the designated hospice

The individual’s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services

The participant's signature on the Hospice Election Statement is the individual’s waiver of rights to any other related services. Services not related to terminal conditions are exempt from this waiver of rights.

MO HealthNet participants who elect hospice do not waive their right to other home and community-based services under the state MO HealthNet plan or a waiver, so long as the services are not duplicative of the services available under the MO HealthNet Hospice Program.

Dual Eligible Hospice Patients (Medicare/MO HealthNet)

Any time a hospice patient is eligible for both Medicare and MO HealthNet at the time of election, the hospice election for both programs must be made simultaneously. Providers should not wait until the patient enters a NF to elect a MO HealthNet hospice. Making the hospice election for both Medicare and MO HealthNet concurrently enables MO HealthNet to avoid duplication of payments for services covered under the Medicare hospice benefit.

If the patient’s MO HealthNet eligibility begins or the hospice becomes aware of the MO HealthNet eligibility after Medicare hospice benefits have been elected, complete the Hospice Information section of the Hospice Election Statement and attach a copy of the Medicare election form indicating the original election date. The signature(s) and dates on the Medicare election may be used as verification of the participant's election date and consent to use hospice benefits when attached to the Hospice Election Statement. The hospice must submit these forms to MHD as soon as the hospice becomes aware of the MO HealthNet eligibility after Medicare hospice benefits have been elected.

International Classification of Diseases Diagnosis Codes

At least one (1) valid terminal International Classification of Diseases (ICD) diagnosis code must be entered in Field 14 of the Hospice Election Statement. Providers should enter an additional ICD diagnosis code in Field 15 of the Hospice Election Statement, if applicable. Providers should only enter terminal ICD diagnosis code(s) on the Hospice Election Statement.

If the patient has multiple terminal diagnoses, the hospice is responsible for all care including prescriptions related to all diagnoses, not just the primary diagnosis. If the ICD diagnosis code is missing from the Hospice Election Statement, all hospice claims will deny. If the terminal diagnosis changes or a new terminal diagnosis is assigned, MHD must be notified specifically stating that fact and identifying the additional ICD diagnosis code and its effective date.

Assignment of the Attending Physician

The attending physician must meet the following guidelines:

A physician who is a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)

Is identified by the individual, at the time the individual elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care

Is the participant's physician of choice who participates in the establishment of the plan of care and works with the hospice team in caring for the patient

Continues to give the medical orders and may have privileges in hospice inpatient care

Their MO HealthNet provider identifier must be included on the Hospice Election Statement and if not provided, MHD will not reimburse the attending physician for services/treatment related to the terminal illness

A hospice physician is available as a consultant on matters of specialized pain and symptom control and to provide physician care when the patient and/or the attending physician prefers. The MO HealthNet hospice election does not affect either the personal or financial relationship between a patient and the attending physician.

If a hospice patient changes attending physicians, the hospice must notify the MHD Hospice Unit. The notification must include the patient’s name and MO HealthNet Identification Number (Designated Client Number (DCN)), a statement that the patient has chosen a new attending physician, the attending physician’s name, the attending physician’s MO HealthNet Identification Number, and the effective date of change.

Development of the Plan of Care

After an individual has been certified as terminally ill and has elected hospice services, a plan of care must be established before services can be rendered. Information regarding the patient’s condition and treatment should be as specific as possible. All services rendered to the participant must be consistent with the plan of care.

In establishing the initial plan of care, the member of the basic interdisciplinary group who assesses the patient’s needs must meet or call at least one (1) other group member (nurse, physician, medical social worker, or counselor) before writing the initial plan of care.

At least one (1) of the persons involved in developing the initial plan must be a nurse or physician and the physician must sign the plan of care.

The plan must be established on the same day as the assessment if the day of assessment is to be a covered day of hospice care.

The other two (2) members of the basic interdisciplinary group must review the initial plan of care and provide their input to the process of establishing the plan of care within two (2) calendar days following the day of assessment.

Signatures of all parties are required within 10 days of establishment of the plan of care. The initial plan of care, as well as significant updates to the plan of care must be maintained in the hospice provider’s file.

Refer to Section 3.2 in this manual for more information on the plan of care.

Pharmacy Reimbursement

The hospice provider is responsible for all medications needed for the palliation and management of the terminal illness and related conditions as required by 42 CFR 418.96. The plan of care must indicate all medication the patient uses and whether the medication is related to the terminal illness. MHD reimburses MO HealthNet pharmacy providers for pharmacy claims which are not related to the hospice patient’s terminal diagnosis. It is the responsibility of the hospice to provide documentation that verifies that specific medication is not related to the terminal diagnosis. The hospice should provide a letter or statement to the pharmacy that includes the following information:

Patient name

Patient MO HealthNet ID Number (DCN)

Service dates

Drug name(s)

Statement that the named drug(s) are not the responsibility of the hospice

Medication List

A medication list must be compiled per individual patient and kept in the individual patient's file. Refer to Section 3.2 in this manual for more information.

Prior Authorization

It is the hospice's responsibility to obtain prior authorization (PA) for drugs on the Hospice Fiscal Edit when the drug is not related to the terminal illness or related conditions. PA requests are processed by calling the Pharmacy and Medical Pre-Certification Help Desk at (800) 392-8030 or by faxing a Drug PA to (573) 636-6470.

It is the hospice's responsibility to reimburse the pharmacy for drugs MO HealthNet has deemed related to the participant's terminal condition(s).