S.C. Medicaid Hospice Services Provider Manual § 2

ELIGIBILITY

In order for a Medicaid beneficiary to be eligible to elect hospice care under Medicaid, the

beneficiary must be certified as being terminally ill. An individual is considered terminally ill if he or

she has a medical prognosis that his or her life expectancy is six months or less if the disease runs

its normal course

ELECTION PROCEDURES

Individuals who elect to receive hospice care must file a Medicaid Hospice Election Form

(Department of Health and Human Services [DHHS] Form 149) (see Forms section) with a

particular hospice. This required form includes the hospice provider identifying information. An

election may also be filed by a family member or a patient representative. With respect to an

individual granted the power of attorney for the patient or acting as an agent of the patient under a

Durable Power of Attorney for Health Care, state law determines the extent to which the individual

may act on the patient’s behalf. All forms must be filled out completely to be accepted by the South

Carolina Department of Health and Human Services (SCDHHS).

An election to receive hospice care will be considered to continue through the initial election period

and through any subsequent election periods without a break in care as long as the individual

remains in the care of the hospice and does not revoke the election. An individual may designate an

effective date for the election period that begins with the first day of the hospice care or any

subsequent day of hospice care, but an individual may not designate an effective date that is earlier

than the date the election is made.

For purposes of the Medicaid hospice benefit, a nursing facility (NF) can be considered the

residence of a beneficiary. A beneficiary residing in such a setting may elect the hospice benefit.

If the hospice is placing a patient in a NF utilizing a Medicaid-certified bed, the procedures for pre-admission screening by Community Long Term Care must be followed.

Revoking Hospice Election

An individual or legal representative may revoke the election of hospice care at any time. To do so,

the individual must file a Medicaid Hospice Revocation Form (DHHS Form 153) with the hospice,

along with a signed statement indicating all of the following:

• That the beneficiary revokes the election for Medicaid coverage for any remaining days in the

election period.

• That the beneficiary is aware of the revocation.

• Why the beneficiary has chosen to revoke hospice services.

An individual may not designate an effective date earlier than the date the revocation is made.

Upon revoking the election of Medicaid coverage of hospice care for a particular election period, an

individual resumes Medicaid coverage of the benefits waived when hospice care was elected,

effective on the date of revocation. The hospice must submit the Medicaid Hospice Revocation

Form (DHHS Form 153) to SCDHHS within five working days of the revocation. An individual may at

any time elect to receive hospice coverage for any other hospice election periods for which he or

she is eligible.

When a beneficiary is noncompliant, the hospice may advise the beneficiary of the option to revoke

the benefit, and any advantages and disadvantages related to the decision. A beneficiary is noncompliant if any of the following occur:

• The beneficiary seeks aggressive treatment for the terminal illness.

• The beneficiary receives treatment in a facility that does not have a contract with the hospice.

• The beneficiary receives treatments that are not in the hospice plan of care (POC) or are not

pre-authorized by the hospice.

Discharge

A hospice can discharge (not revoke) a beneficiary for the following reasons:

• The beneficiary dies.

• The beneficiary is noncompliant.

• The beneficiary is determined to have a prognosis greater than six months.

• The beneficiary moves out of the hospice’s geographically defined service area.

• The safety of the patient or of the hospice staff is compromised.

The hospice must make every effort to resolve these problems satisfactorily before it considers

discharge an option. All efforts by the hospice to resolve the problem must be documented in detail

in the beneficiary’s clinical record. The hospice must notify the SCDHHS hospice program manager

and the state survey agency of the circumstances surrounding controversial impending discharges

where noncompliance or safety issues are the cause or the causes for discharge. Whatever the

reason for discharge, the hospice must clearly document why the patient was discharged from the

hospice benefit.

When discharging a beneficiary, the Medicaid provider must submit a Medicaid Hospice Discharge

Form (DHHS Form 154) to SCDHHS within five working days of the discharge. When discharging

for reasons other than death, the hospice must send a copy of the Medicaid Hospice Discharge

Form to the beneficiary or responsible party upon discharge. The reverse side of the Medicaid

Hospice Discharge Form contains the appeals procedures provided for each Medicaid beneficiary

when adverse action is taken against that beneficiary. When forwarding a copy of this completed

form, the provider must ensure that the reverse side of the form is included.

A hospice provider may not discharge a beneficiary who has revoked the Medicaid hospice benefit.

Therefore, a Medicaid Hospice Discharge Form should not be completed when a revocation is

made.

Appeals

When a Medicaid beneficiary is discharged from a hospice program for one of the reasons listed

under “Discharge,” the beneficiary has the right to a fair hearing regarding the decision.

Beneficiaries and their legal representatives have the right to appeal the hospice discharge within

30 days of the receipt of the Medicaid Hospice Discharge Form by submitting a written request to

the following address:

Department of Health and Human Services

Director, Division of Appeals and Fair Hearings

Post Office Box 8206

Columbia, SC 29202-8206

The request must state specifically, which issues are being appealed and must be accompanied by

a copy of the Medicaid Hospice Discharge Form.

A request for a fair hearing is considered filed if postmarked by the thirtieth calendar day following

receipt of the Medicaid Hospice Discharge Form. Both the Medicaid beneficiary and the provider will

be notified of the date, time, and place the fair hearing will take place.

Dually Eligible Beneficiaries

If an individual is eligible for Medicare as well as Medicaid, the hospice benefit must be elected and

revoked simultaneously under both programs. In other words, if a Medicaid beneficiary elects the

hospice Medicaid benefit and is also eligible for Medicare, then the beneficiary must also elect the

Medicare hospice benefit. If a Medicare beneficiary elects the hospice Medicare benefit and is also

eligible for Medicaid, then the beneficiary must also elect the Medicaid hospice benefit.

For dually eligible beneficiaries, Medicare is the primary payer for the hospice benefit, though the

Medicaid hospice election process must also be completed. Revocation, discharge and change of

provider procedures must be followed and designated forms completed as specified in this section.

A flowchart of the documentation submission process can be found at the end of this section.

Retroactive Eligibility

Individuals who have applied for Medicaid eligibility can elect the hospice benefit while their

applications are pending approval. If an individual is determined eligible, SCDHHS may pay the

hospice for services delivered while the eligibility determination was pending. Eligibility can be

retroactive for a maximum of three months.

If an individual has not been determined Medicaid eligible but meets all other criteria to elect the

Medicaid hospice benefit, he or she may elect the hospice benefit by completing the documentation

required for prior authorization of hospice services. (i.e., DHHS Form 149, Medicaid Hospice

Election Form [include the effective date in the Elective Date block], Physician

Certification/Recertification, SCDHHS Form 151, Hospice POC and supporting documentation).

Once the individual is notified of his or her Medicaid eligibility, the beneficiary identification number

must be entered on the signed and dated election form and physician certification form (DHHS 149

and 151). At this time, all documentation must be submitted to QIO to request prior authorization of

hospice services. The hospice agency may continue to verify the beneficiary’s eligibility status by

using the Web Tool. See the Provider Administrative and Billing Manual for more information.

A hospice agency cannot submit a claim form for payment until after the beneficiary has been

determined Medicaid eligible, and at no time can reimbursement be requested for dates of service

prior to the actual date of election.

A hospice agency that elects an individual whose Medicaid eligibility has not been determined

assumes all liability for services the individual may receive, whether that individual is determined to

be eligible. All liability rules are effective as though the individual has already been determined to be

eligible (e.g., hospitalizations related to the terminal illness). A hospice agency cannot solicit

payment from the individual for services that may be provided after the Medicaid hospice benefit

has been elected.

General information regarding retroactive eligibility claim submission can be found in the Provider

Administrative and Billing Manual.

Hospice Care for Minors (Persons Under the Age of 21) Enrolled in Medicaid

SCDHHS will provide reimbursement for hospice services for minors under 21 years of age in

conjunction with curative treatment of the child’s terminal illness.

Section 2302 of the Affordable Care Act, entitled “Concurrent Care for Children” removes the

prohibition of receiving curative treatment upon the election of the hospice benefit by or on behalf of

minors enrolled in Medicaid or Children’s Health Insurance Program.

This provision does not change the criteria for hospice.

A physician must certify that the minor is terminally ill, with a life expectancy of six months or less.

This provision allows parents with minors under the age of 21, receiving hospice services to no

longer forgo any other services to which the minor is entitled to under Medicaid treatment of the

terminal condition. Services rendered by a provider other than the hospice must be discussed and

coordinated with the hospice provider.

Hospice Services for Residents of NFs or Intermediate Care for Individuals with Intellectual

Disabilities (ICF/IDD)

Participation with Skilled Nursing Facility (SNF), NF, ICF/IID or Non-Certified Facility

The term “home” is not to be limited for hospice beneficiaries. A beneficiary’s home is where he or

she resides. A hospice may furnish routine or continuous home care to a beneficiary who resides in

a SNF, NF or ICF/IID or a facility not eligible for Medicare or Medicaid such as a Community

Residential Care Facility. The facility is considered to be the beneficiary’s place of residence (the

same as a house or apartment), and the Medicaid facility resident may elect the hospice benefit if

he or she also meets the hospice eligibility criteria.

The hospice then assumes full responsibility for professional management of the individual’s

hospice care in accordance with the Hospice Conditions of Participation (42 CFR 418) and makes

any arrangements necessary for inpatient care in a participating Medicare or Medicaid facility.

Notification of NF Utilization

The Medicaid hospice program manager must be notified in writing by the hospice when either of

the following occurs:

• A Medicaid beneficiary who is a NF resident and is also Medicare eligible (referred to as dually

eligible) chooses to elect the hospice benefit.

• A Medicaid-sponsored NF resident elects the hospice benefit under the Medicaid hospice

program.

A Medicaid Hospice Election Form must be completed and forwarded to the hospice program

manager as described under “Election Procedures” with the facility address in the appropriate

section for the beneficiary’s address.

Compliance with SNF/NF and ICF/IID: Conditions of Participation

A Medicaid hospice provider must have a written agreement with a facility specifying that the

SNF/NF Conditions of Participation (42 CFR 483) or the Conditions of Participation for an ICF/IID

(42 CFR 483.400 Subpart I) are applicable to all residents in the facility. Hospice beneficiaries are

no exception. This means that the resident must be assessed using the information contained in the

appropriate assessment instrument; have a POC, which, in this case, will be jointly developed and

agreed upon by the hospice and facility and be provided with all services contained in the POC.

When a resident of a facility elects the Medicaid hospice benefit, the hospice and the facility must

communicate, establish and agree upon one coordinated POC for both providers. The POC must

also reflect the hospice philosophy and be based on an assessment of the individual’s needs and

unique living situation in the NF. The POC must include the individual’s current medical, physical,

psychosocial and spiritual needs. The hospice must designate a registered nurse from the hospice

to coordinate the implementation of the POC.

An emergency plan, including telephone numbers that may be used in cases of beneficiary

emergency, must also be left with the facility.

Professional Responsibility Coordination

The facility and the hospice are responsible for performing their respective functions agreed upon

and included in the POC. The POC should reflect the participation of the hospice, facility and the

resident to the greatest extent possible. The hospice and facility must communicate with each other

when any changes are indicated to the POC.

The hospice retains overall professional management responsibility for directing the implementation

of the POC.

All covered hospice services must be available as necessary to meet the needs of the patient. All

core services must be routinely provided directly by hospice employees and cannot be delegated to

the facility. Nursing care, physicians’ services, medical social services and counseling are core

hospice services.

The facility nursing personnel may assist with the administration of prescribed therapies included in

the POC only to the extent that the hospice would routinely rely on the services of a hospice

patient’s family or caregiver in implementing the POC.

Drugs and medical supplies must be routinely provided as needed for the palliation and

management of the terminal illness and related conditions. Drugs must be furnished in accordance

with accepted professional standards of practice.

Evidence of this coordinated POC must be present in the clinical records of both providers. All

aspects of the POC should reflect the hospice philosophy.

The hospice beneficiary residing in a facility should not experience any lack of facility services or

personal care because of his or her status as a hospice beneficiary. The facility must offer the same

services to its residents who have elected the hospice benefit as it furnishes to its residents who

have not elected the hospice benefit. The hospice beneficiary has the right to refuse any services.

Non-Core Services

The hospice may arrange to have non-core hospice services provided by the facility if the hospice

assumes professional management responsibility for these services and ensures that these

services are performed in accordance with the policies of the hospice and the patient’s POC.

Non-core services are the provision of medical appliances and supplies, including drugs and

biologicals, home health aide services, physical therapy, occupational therapy and speech-language

pathology services.

Hospice Beneficiaries Entering a NF from the Community or a Hospital

When a Medicaid beneficiary who has elected the hospice benefit in the community subsequently

requires placement in a NF for long-term care, additional eligibility determinations must be

completed before the beneficiary can receive Medicaid CLTC sponsorship. The authorization of

medical necessity, or pre-admission review, is a function of LTC). A Pre-Admission Screening and

Annual Resident Review (PASRR) determination is also completed by CLTC, NF or a hospital by a

signed memorandum of agreement (MOA). The financial eligibility portion is determined by Medicaid

eligibility staff.

Level of Care (LOC) Certification

The CLTC nurse consultant must be contacted, and a pre-admission review completed in order for a

beneficiary to be determined medically eligible. Medicaid vendor payment is authorized by the

issuance of the LOC Certification letter, DHHS Form 185, which certifies medical necessity.

If a beneficiary receives a Medicare-qualifying skilled service for a condition unrelated to the

terminal diagnosis, Medicare will pay the NF and hospice benefit.

If a beneficiary receives a Medicare-qualifying skilled service for a condition related to the terminal

diagnosis, Medicare will only pay for the hospice benefit. In this situation, CLTC will certify for

Medicaid sponsorship if all criteria are met.

If the beneficiary is not Medicare eligible, CLTC will certify the beneficiary following its usual

procedures.

PASRR

The PASRR screening is a federally mandated program that requires each state to screen

individuals for any indication of mental illness or intellectual disabilities. CLTC will refer to the

appropriate agency if the screenings reveal indicators of mental illness or intellectual disabilities. A

referral must be made to the appropriate CLTC office for this screening. Most nursing facilities and

hospitals have a Memorandum of Agreement with CLTC to perform this screening.

Financial Eligibility

The beneficiary must meet additional financial eligibility requirements before Medicaid will sponsor a

stay in a long-term care facility. Once the SCDHHS eligibility worker determines financial eligibility, a

signed DHHS Form 181 is sent to the NF.

The NF attaches a copy of the DHHS Form 181 to the billing invoice for the resident at the end of

the billing period and forwards that invoice to the hospice agency for reimbursement. The DHHS

Form 181 verifies the resident’s applicable recurring income.

If the hospice beneficiary decides to revoke his or her hospice election, the hospice provider must

notify the NF of the revocation in writing, indicating the effective date. The NF would then initiate

billing procedures as usual.

Medicaid Bed Hold Days

If a Medicaid NF resident should require a short-term hospitalization with the expectation of

returning to the NF, the NF will reserve the bed for up to 10 days. Reimbursement for the bed hold

will be the responsibility of the hospice agency. Medicaid will reimburse the hospice agency for up to

10 consecutive bed hold days if both criteria, short-term stay and expectation of returning to the

facility, are met. However, Medicaid reimbursement will not be provided for NF bed-hold days for

dually eligible and Medicaid-only hospice beneficiaries receiving general inpatient (GIP) care. If the

beneficiary intends to return to the NF, it is the hospice responsibility to negotiate room and board

rate with the NF to hold the patient’s bed.

SCDHHS will continue to reimburse hospice providers limited to 10 NF bed-hold days in

combination with payment for routine care services provided to the beneficiary

Therapeutic Care Deinstitutionalization Program

A Medicaid NF resident may leave the facility for up to eighteen days each fiscal year with

expectation of Medicaid sponsorship for the absence. Each period of leave may be for a maximum

of 9 days, and periods may not be consecutive. The POC must include the attending physician’s

authorization for home leave.

Chart entries should include:

• The length of time for which the leave was approved.

• The goal of the leave.

• On the resident’s return, the results of the leave in relation to the goal.

The hospice agency then submits a claim to the Medicaid agency for reimbursement for these days

and subsequently reimburses the NF. The hospice agency is expected to continue with routine

home care should the resident leave the facility.

Notification of Death

The hospice agency is required to notify the NF and the SCDHHS eligibility worker of the date of

death, using the SCDHHS Form 154, Medicaid Hospice Discharge Form. Due to the potential

difficulty of obtaining a signature on the Form 154 following the death of a beneficiary, the signature

is not required on the form in the circumstance of discharge by death. After notification, the NF will

submit a final invoice to the hospice agency. This invoice will not include the date of death for

reimbursement.