Utah Medicaid Provider Manual, Hospice Care Services § 8-9.8

Hospice agencies may not initiate discharge of a patient from hospice care

except in the following circumstances:

• The member moves out of the hospice agency’s geographic service area or

transfers to another hospice agency by choice.

• The hospice agency determines that the patient no longer meets the

eligibility criteria for hospice.

• The hospice agency determines that the member’s behavior (or the

behavior of other persons in the patient’s home) is disruptive, abusive, or

uncooperative to the extent that delivery of care to the member or the

ability of the hospice to operate effectively is seriously impaired. This type

of discharge is called “for cause. ” When it becomes necessary to discharge

for cause, the following steps must be taken prior to discharge:

1. Advise the member that a discharge for cause is being considered,

2. Make a diligent effort to resolve the problem(s) that the patient's

behavior or situation presents,

3. Ascertain that the discharge is not due to the member’s use of

necessary hospice care services, and

4. Document the problem and efforts to resolve the problem in the

member’s medical record.

Before discharging a patient for any reason, the hospice agency must obtain a

physician's written discharge order from the hospice agency's medical director.

If a patient also has an attending QHP, the hospice agency must consult the QHP

before discharge and the attending QHP must include the review and decision in

the discharge documentation.

A member, upon discharge from the hospice during a particular election period,

for reasons other than immediate transfer to another hospice:

• Is no longer covered under Medicaid for hospice care,

• Resumes Medicaid coverage of the benefits waived during the hospice

coverage period; (for adult members), and

• May at any time elect to receive hospice care if the member is again

eligible to receive the benefit in the future.

The hospice agency must have in place a discharge planning process that

considers the prospect that a patient's condition might stabilize or otherwise

change if that patient cannot continue to be certified as terminally ill. The

discharge planning process must include planning for any necessary family

counseling, patient education, or other services before the patient is discharged

because the patient is no longer terminally ill.

If the hospice agency or Medicaid determines that a member is not terminally ill

while receiving hospice care under this manual, the member is not responsible

to reimburse Medicaid. If Medicaid denies reimbursement to the hospice agency,

the hospice agency may not seek reimbursement from the member.