W. Va. BMS Provider Manual § 509.3.2

Services that are covered by the Hospice program are those that are reasonable and necessary for the

palliation and management of the terminal illness and related conditions. An interdisciplinary plan of care

must be established before care begins and must detail the type, scope, and frequency of those services

to address the needs of the member and the member’s family. All care must be planned, delivered and

coordinated in accordance with 42 CFR §418.56 and §418.200.

There are two types of Hospice services:

1. Core Hospice Services: Are to be provided directly by Hospice employees/contractors/volunteers.

Services include:

•

Nursing Care: Must be provided by an RN or by a licensed practical nurse (LPN) under the

supervision of an RN.

•

Medical Social Services: Must be provided by an LSW working under the direction of a

physician.

•

Physician Services: Must be provided by a professional who is acting within the scope of the

physician’s license and who is either an MD, a DO, Doctor of Podiatry (DPM), Doctor of

Dentistry (DDS), Doctor of Optometry (OD), or a Doctor of Chiropractic (DC). The medical

director of the Hospice or the physician member of the IDT must be a licensed MD or DO.

•

Counseling Services: Must be provided to the terminally ill individual and the family members

or other persons caring for the individual at home. Counseling, including dietary counseling,

may be provided both for the purpose of training the member’s family or other caregivers to

provide care, and for the purpose of helping the member and those caring for him or her to

adjust to the member’s approaching death. Bereavement counseling consists of counseling

services provided to the individual’s family up to one year after the individual’s death.

Bereavement counseling is a required Hospice service, but it is not reimbursable (see West

Virginia State Plan Hospice Services Appendix 3.1-C).

2. Other Hospice Services: A Hospice provider must make available, services that are not

considered “core” services. These may be provided by the employees of the Hospice provider or

they may be arranged by contractual agreement. They include:

•

Drugs and Biologicals: Must be identified as those documented in the Hospice Plan of Care

and provided by the Hospice while the member is under Hospice care. Hospice covered

drugs are those related to the palliation and management of the terminal illness and related

conditions necessary to meet the needs of the member (in accordance with West Virginia

State Plan Appendix 3.1-A and 3.1-B, and 42 CFR §418.56(c)(4), §418.106, and §418.202

(f))).

o

Management, ordering, dispensing, administration, labeling, disposition, and storing

of drugs and biologicals must follow the policies and procedures in accordance with

42 CFR §418 Hospice Care;

o

Home Health program services, drugs, and biologicals obtained through the West

Virginia Medicaid Pharmacy program for the palliation and management of symptoms

related to the member’s terminal illness;

o

Coverage of medications to control pain and nausea unless justified by pre-existing

conditions;

NOTE: The West Virginia Pharmacy program will provide medications that are unrelated to the

member’s

terminal illness. The Hospice provider must submit the appropriate documentation to

justify the

member’s condition is unrelated to his/her terminal illness. (Refer to the Glossary section

regarding Pre-existing Conditions and Related Condition).

•

Durable Medical Equipment and Supplies: Are to be available for comfort or self-help related

to the palliation of the terminal illness and related conditions (in accordance with West

Virginia State Plan Appendix 3.1-A and 3.1-B page 7, and 42 CFR §418.56, §418.202 (f), and

§418.106).

•

Short-term inpatient care: Is to be provided either to provide respite for family or other

persons caring for the member at home, or for control of pain or symptoms arising from the

terminal illness and related conditions that is not possible in any other setting (in accordance

with West Virginia State Plan Appendix 3.1-A and 3.1-B page 7, and 42 CFR §418.202 (e)).

•

Home Health and Homemaker Services: Must meet the specifications of 42 CFR §484.36,

and must be provided under the supervision of an RN. Home health aides and homemaker

service providers may provide personal care services and household services for safety and

sanitation of the member, appropriate for the Plan of Care.

•

Rehabilitation Services: include physical and occupational therapies and speech pathology

used for symptom control or to maintain activities of daily living and functional skills (in

accordance with West Virginia State Plan Appendix 3.1-C and 42 CFR §418.202).

When a Hospice contracts or arranges for any service, the Hospice must maintain professional, financial,

and administrative responsibility for the services and must ensure that all staff members meet the

regulatory qualification requirements.

For out-of-state services, refer to Chapter 300, Provider Requirements and West Virginia State Plan,

Attachments 3.1-D.

The Hospice must maintain and document an effective infection control program that protects members,

families, visitors, and Hospice personnel by preventing and controlling infections and communicable

diseases in accordance with 42 CFR §418.60 (a)(b)(c).

The Hospice must comply with all applicable federal, state, and local emergency preparedness

requirements. The Hospice must establish and maintain an emergency preparedness program that meets

the requirements according to 42 CFR §418.113 (a thru e).