N.C. Medicaid Clinical Coverage Policy No. 3D § 7.3.3.2

Medicaid-only and dually eligible beneficiaries residing in primary private

residences may receive Hospice and State Plan Personal Care Services

(PCS) in accordance with 42 CFR 418.76 (i). State Plan Personal Care

Services must be used to the extent that the hospice would routinely use

the services of a hospice beneficiary’s family in implementing a

beneficiary’s plan of care. The hospice provider shall coordinate its

hospice aide and homemaker services with the prior approved personal

care services required to meet the beneficiary’s needs. Hospice and PCS

services are provided with approved and documented coordination of

services. Hospice providers are to submit the Hospice PCS Coordination

Form (DMA-3165) via fax to NC Medicaid within five (5) days of

hospice admission. Refer to the NC Medicaid website or the NC Tracks

Provider Portal for links to this form.

If PCS services are in place prior to hospice:

a. The hospice provider contacts the PCS provider to coordinate the plan

of care and scheduling of services.

b. The hospice provider will submit the Hospice-PCS Coordination

Form (DMA-3165) to NC Medicaid within five days of admission.

c. The hospice provider will submit the Hospice Aide Plan of Care to the

PCS provider.

If Hospice is in place prior to PCS request:

a. The hospice provider submits the Hospice-PCS Coordination Form

(DMA-3165) to NC Medicaid to indicate the service gap necessitating

the addition of PCS.

b. The hospice physician shall complete the Request for Independent

Assessment for Personal Care Services (PCS) Attestation of Medical

Need (DMA-3051) and faxes it to the Independent Assessment

agency.

c. Once PCS is authorized, the hospice provider contacts the PCS

provider to coordinate the plan of care and scheduling of services.

d. The hospice provider submits the Hospice Aide Plan of Care to the

PCS provider.

e. The PCS provider submits the Online Services Plan from QiReport to

the hospice provider. The hospice providers submit the PCS reports to

NC Medicaid for Medicaid beneficiaries only.

The hospice aide services must be utilized to the extent that they would be

if PCS were not available. NC Medicaid or its contractors may conduct

retrospective reviews of PCS and hospice services. Medicaid payments

for personal care services provided to a beneficiary also receiving hospice

services, regardless of the payment source for hospice services, must be

supported by documentation in the medical record of both providers. If

duplication of services is found, NC Medicaid may recover payment for

those services.

a. Aide Services

The hospice provider shall coordinate its hospice aide and homemaker

services with the Personal Care Services required to meet the

beneficiary’s needs. The hospice provider shall make hospice aide and

homemaker services available and adequate in frequency to meet the

needs of the hospice beneficiary.

b. Service Coordination and Communication

The hospice provider is responsible for communicating with other

providers to ensure that coordination of care occurs. The hospice

provider must ensure that a thorough interview process is completed

when enrolling a recipient to identify all other Medicaid or other state

and/or federally funded program providers of care. This requirement

applies to Medicaid beneficiaries as well as the dually eligible

Medicare/Medicaid beneficiary. Communication to coordinate care

must be documented in each provider’s medical record for the

beneficiary.

If the hospice provider determines prior to admission that PCS is in

place for the beneficiary, the hospice provider contacts the PCS

provider, if known, to discuss the services of the PCS provider that the

beneficiary is receiving. This allows for better communication with the

beneficiary and family during the hospice admission visit to outline the

differences in services.

If the PCS provider is not determined prior to admission, hospice

provider contacts the provider immediately after the admission visit to

discuss the coordinated plan of care.

c. Plan of Care

The hospice provider and the PCS provider agency shall develop a plan

of care (POC) in coordination with the beneficiary, the caregiver and

each other. The POC must clearly and specifically detail the aide

services to be provided along with the frequency of services by each

provider to ensure that services are not duplicative, and the

beneficiary’s daily needs are met.

This process involves coordinating tasks and services as well as the

time of day that the beneficiary may receive visits from each

provider’s aide. Hospice aide and PCS aide hours cannot overlap so

the two providers shall coordinate visits to ensure separation. The

hospice providers and the PCS provider shall give education to the

aides that if they arrive at the home and the other aide is there, they

shall report this to their respective providers and leave the home. Any

changes in scheduling for either providers must be reported to the other

to avoid duplication of services at the same time.

The hospice providers and the PCS provider shall maintain a copy of

the plan of care in their respective medical records.