N.Y. Medicaid Hospice Program Manual Policy Guidelines, Section I, Plan of Care

The hospice provider develops an individualized plan of care (POC), established by an

interdisciplinary group (IDG) and overseen by a registered nurse (RN) coordinator. The

POC must include all services necessary for the palliation and management of the

terminal illness and related conditions of the individual. Hospices must identify needs in

the comprehensive assessment that are not related to the terminal illness and related

conditions. The assessment should document that the hospice is aware of these needs

and identify who is addressing them. The hospice should identify what durable medical

equipment (DME) is needed and the services to be provided to address the terminal

illness and related conditions. The POC should include all diagnoses related to the

terminal illness and include those diagnoses directly related to the services the patient is

receiving from non-hospice healthcare providers. The hospice must provide for an

ongoing sharing of information with other non-hospice healthcare providers furnishing

services unrelated to the terminal illness and related conditions.

In accordance with DHCBS 22-15, DOH-5778 Entity/Facility Notification of Hospice Non-Covered Items, Services, and Drugs is to be completed by the hospice provider and

shared with other medical providers and/or facilities who provide services to the patient

including local departments of social services and Medicaid Managed Care

Organizations (MMCOs). In Section II of DOH-5778, the hospice is to provide the

patient's diagnoses information, and identify whether the diagnoses are related (Section

II.A.) or unrelated (Section II.B.) to the patient's terminal illness and its associated

conditions. It is expected that the field will not include a code (e.g., C25.9) but rather will

include appropriate terminology reflective of the diagnosis.

The above criteria applies to all Medicaid recipients (i.e., Medicaid Fee-for-Service,

Mainstream Managed Care and Managed Long Term Care).