Vt. Medicaid Hospice Provider Manual § 5

Medicaid follows Medicare Hospice rules unless otherwise noted.

Covered Services

Appropriately qualified personnel must perform all services. The nature of the service determines

the coverage category of the service. The following services are covered hospice services:

• Physician services - a physician must perform physicians’ services as defined in 42 CFR

410.20(b)(1)(1).

• Nursing care (routinely available and/or on call on a 24-hour basis, 7 days a week)

provided by or under the supervision of an RN functioning within a plan of care developed

by the hospice Interdisciplinary Team (IDT) in consultation with the members attending

physician, if the member has one.

• Medical social services by a qualified social worker under the direction of a physician.

• Counseling including, but not limited to, bereavement, dietary, and spiritual counseling with

respect to care of the terminally ill member and adjustment to death. The hospice must

make bereavement services available to the family and other members identified in the

bereavement plan of care up to 1 year following the death of the member.

• Hospice aide may provide personal care.

• Physical Therapy, Occupational Therapy, and Speech Therapy may be provided for

purposes of symptom control or to enable the member to maintain activities of daily living

and basic functional skills.

• Medical supplies and appliances - Equipment is provided by the hospice for use in the

member’s home while the member is under hospice care. Medical supplies include those

that are part of the written plan of care and that are for palliation and management of the

terminal illness or related conditions.

• Drugs and biologicals - Hospices are to provide all drugs and biologicals for the palliation

and management of pain and symptoms of a member’s terminal illness and related

conditions.

• Other Items and Services - Ambulance transports of a hospice member, which are related

to the terminal illness, and which occur after the effective date of election, are the

responsibility of the hospice.

• Short term inpatient care (including respite care and interventions necessary for pain

control and acute and chronic symptom management) in a Medicare/Medicaid participating

facility.

• Routine Home Care is received at the member’s home; it is not continuous home care.

Routine home care (revenue codes 651 [high rate for 0 – 60 days], [low rate for 61+ days]

and 552 [service intensity add-on (SIA) payment for last seven days of life]) is reimbursable

to hospice providers for each day the member is under the care of the hospice and not

receiving another level of care, whether or not the member is visited in the home by the

hospice provider on the days being billed. Revenue code 651 and is reimbursable for days

when no home visit is made, only if the service(s) provided are consistent with the

member’s plan of care.

• Continuous Home Care consists of continuous, predominately skilled nursing care provided

on an hourly basis, for a minimum of eight hours during brief crisis periods. Home health

aide and/or homemaker services may also be provided. When fewer than 8 hours of care

are required, the services are covered as routine home care rather than continuous home

care. Continuous home care is only furnished during brief periods of crisis and covered only

as necessary to maintain the terminally ill member at home.

• Respite Care occurs when the member receives care in an approved inpatient facility on a

short-term basis to provide relief for family members or others caring for the member. Each

episode is limited to no more than five days.

• General Inpatient Care General inpatient care occurs when the member receives general

care in an inpatient facility for pain control, or acute/chronic symptom management that

cannot be managed in other settings.

Non-Covered Services

When a member is enrolled in hospice, separate payment will not be made, or treatment

authorizations approved, for the following:

• Treatment intended to cure terminal illness and/or related conditions.

• Prescription drugs that aren’t for terminal illness or related conditions.

• Care from any provider that wasn’t set up by the hospice medical team

• Hospital outpatient services (like in an emergency room), care received as a hospital

inpatient, or ambulance transportation, unrelated to terminal illness and related conditions,

unless the hospice team arranges it.

• Room and board.

More information about Medicare hospice benefits.