PURPOSE: This rule establishes the regulatory basis for administration of a medical assistance program of hospice care as mandated by House Bill 1139, 84th General Assembly. More specific details of the conditions for prouider participation, criteria and methodology of, ?r@der reimbursement, recipient eh&hty, and amount, duration and scope ofseruices cowed are included in the provider program manual. The Missouri Title XIX Hospice Services Program is similar to the Title XVIII Medicare Hospice Services program as defined and prescribed in Title 42, Code ofFederal Regulations part 418.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or ezpensiue. The entire text of the materkxl referenced has been f&d with the secretary of state. This material may be found at the Office of theSecretary of Stateorat the headquarters of theagency and isavailable to any interested person at a cost established by state law.

1. (1) Administration. The Hospice Program shall be administered by the Department of Social Services, Division of Medical Services. The medical services covered and not covered, the program limitations and the maximum allowable fee for all covered services shall be determined by the Department of Social Services, Division of Medical Services.
2. (2) Persons Eligible. Any person who is eligible for medical assistance benefits from the Department of Social Services is certified by a physician to be terminally ill with a medical prognosis of life expectancy of six (6) months “7 less and who elects hospice benefits is eligible. The individual must agree to seek only palliative care for the duration of the hospice enrollment.

3. (3) Enrollment of Recipient. The components involvedin hospiceenrollment are-physician certification; election procedures, including election statement, revocation and change; the assignmentofan attending physician; andthe development of the plan of care.

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   Judith K. Moriarty (Z/28/94) SaerDtary Of state

   1. (A) Physician Certification. The hospice must obtain the certification that an individual is terminally ill in accordance with the following procedures:

      1. 1. For the first period of hospice coverage

(ninety (90) days), the hospice must obtain, no later than two (2) calendar days after hospice care is initiated, written certification statements signed by the medical director of the hospiceor thephysicianmemberofthe hospice interdisciplinary group and the individual’s attending physician (if that attending physician is other than a hospice staff member). The certification must include the statement that the individual’s medical prognosis is a life expectancy of six (6) months or less and the signature(s) of the physician(s). If the hospice does not obtain written physician certification within two (2) days of the initiation of hospice care, a verbal physician certification may be obtained within the two (2) days. However, a written certification must be obtained no.later than eight (8) days after care is initiated. Payment will not be made for days prior to the written certification if the verbal certification requirement is not met; and

1. 2. For any subsequent period, the hospice

must obtain, no later than two (2) calendar days after the beginning of that period, a written certification statement prepared by the medical director of the hospice or the physician member of the hospice’s interdisciplinary group. The certification must include the statement that the individual’s medical prognosis is a life expectancy of six (6) months or less and the signature(s) ofthephysician(s). The hospice must maintain the certification statements.

1. (B) Election Procedures. To elect hospice services, an individual must file a Missouri Medicaid Hospice Election Statement (MO 886.2491) with a Medicaid participating hospice provider. An election may also he filed by a representative acting pursuant to state law. With respect to an individual granted the power of attorney for the recipient,, state law determines the extent to which the Individual may act on the patient’s behalf.

   1. 1. Eleciion period. 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.

1. 2. Waiver of Medicaid fee-for-service payments related to the terminal illness. In order to elect hospice services,, the individual mustwaiveal1rightstoMedica~dpaymentsfor services that would be covered under the Medicare program for the duration of the election of hospice care for the following services:

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   13 CSR 70-50

   1. A. Hospice care provided by a hospice

other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and

1. B. Any Medicaid services that are

related to the treatment of the terminal condition for which hospice care was elected or a related condition, “I that are equivalent to hospice care except for services-

1. (1) Provided(eitherdirectly orunder

arrangement) by the designated hospice;

1. (II) Provided by another hospice

under arrangements made by the designated hospice; or

1. (III) Provided by the individual’s

attending physician if that physicianisnot an employee of the designated hospice or receiving compensation from the hospice for those services.

1. 3. Election, revocation and change of

hospice.

1. A. Election periods. The periods of care

are available in the order listed as follows and may be elected spearately at different times. An individual may elect to receive hospice care during one (1) “I more of the following election periods:

1. (I) An initial ninety (90).day period;
2. (II) A subsequent ninety (90).day

period;

1. (III) A subsequent thirty (30).day

period; and

1. (IV) Unlimited subsequent ninety

(90).day periods.

1. B. Election statement. The election

statement must include the following items of information:

1. (I) Identification of the particular

hospice that will provide careto theindividual;

1. (II) The individual’s “I representa-

tive’s acknowledgement that s/he has been given a full understanding of hospice care;

1. (III) The individual’s or representa-

tive’s acknowledgement that s/he understands that certain Medicaid services are waived by the election;

1. (IV) The effective date of the election;

   1. (V) The name of the attending phy-

sician;

1. (VI) Thesignatureoftheindividualor

representative; and

1. (VII) The signature of the witness

when the recipient’s representative signs the form.

1. C. Revocation. An individual or repre-

sentative may revoke the election of hospice care at any time. To revoke the election of hospice care, the individual, or representative, must file a revocation of hospice benefit statement with the hospice. This statement must include a signed statement that the individual revokes the election for Medicaid coverage of hospice care for the remainder of

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13 CSR 70-50-SOCIAL SERVICES

that election period. The date that the revocationistobeeffectiveisthedateofthesignature or may be a later date subsequent to the date of signature. The individual forfeits coverage for any remaining days in that election period. The individual or representative, may not designate an effective date earlier than the date that the revocation statement is signed. 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. An individual may elect at any time to receivehospice coverage for anv other hosnice election ueriods for which s/he is eligible:

1. D. Change of hosoice. An individual

may change, once in ea& election period, the designation of the particular hospice from which s/he elects to receive hospice care. The change of the designated hospice is not considered a revocation of the election. To change the designation of hospice providers, the individual must file with the hospice from which s/he has received care and with the newly designated hospice a signed statement that includes the following information: the name of the hospice from which the individual has received care, the name ofthe hospice from which s/he plans to receive care and the date the change is to be effective.

1. (C) Attending Physician. The attending physician is a doctor of medicine or osteopathy and is identified by the individual, at the time s/he elects to receive hospice care, as having the most significant role in the determination and delivery of the individual’s medical care. The attending physician is the recipient’s physician of choice who participates in the establishment of the plan of care and works with the hospice team in caring for the patient. The physician continues to give the medical orders and may have privileges in the hospice inpatient care. Medicaid will make payments directly to a hospice recipient’s attending physician if the physician is not employed by the hospice provider.
2. (D) Plan of Care. After an individual has been certified as terminally ill and has elected hospice services, a plan of care must be establishedbeforeservicescan berendered. All services rendered to the recipient must be consistent with the plan of care. In establishing the initial plan of care, the member of the basic interdisciplinary group who assesses the patient’s needs must meet with or call at least one (1) other group member (nurse, physician, medical social worker or counselor) before writing the initial plan of care. At least one (1) of the persons involved in developing the initial plan of care must be a nurse or a physician and the physician must sign the plan of care. This plan must be established on the same day as the assessment if the day of assessment is to be a covered day of hospice care. The other two (2) members of the basic interdisciplinary group must review the initial plan of care and provide their input to the process of establishing the plan of care within two (2) calendar days following the day of assessment. Signatures of all parties are required.

1. (4) Provider Participation. To be eligible for participation in the Missouri Medicaid Hospice Program, a provider must meet the following criteria:

   1. (A) Be certified as a Medicare hospice provider; and
   2. (B) Be enrolled as a Medicaid hospice provider.

2. (5) Benefits andLimitations. Allservicesmust be performed by appropriately qualified personnel. Nursing care, physician’s services, medical social services and counseling are core hospice services and must routinely be provided directly by hospice employees. A hospice must ensure that substantially all the core services are routinely provided directly by hospice employees. A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patientsduringperiodsofpeakpatientloadsor under extraordinary circumstances. If contracting is used, the hospice must maintain professional, financial and administrative responsibility for the services and must assure that the qualifications of staff and services provided meet all requirements. The following services are hospice-covered services when specified in the individual’s plan of care:

   1. (A) Nursing care provided by or under the supervision of a registered nurse (RN);
   2. (B) Medical social services provided by a social worker who has at least a bachelor’s degree from a school accredited or approved by the Council on Social Work Education and who is working under the direction of a physician;
   3. (C) Physician’s services performed by a doctor of medicine or osteopathy to meet the general medical needs of the individual to the extent that these needs are not met by the attending physician;

   4. (D) Counselingservicesmustbe availableto both the patient 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 individual’s family or other caregiver to provide care and for the purpose of helping the individual and those caring for him/her to adjust to the individual’s approaching death;

      COOE OF STATE REGULATIONS

   5. (E) There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery (up to one (1) year following the death of the patient);
   6. (F) Dietary counseling, when required, must be provided by a qualified individual;
   7. (G) Spiritual counseling must include notice to the patient as to the availability of clergy;
   8. (H) Counseling may be provided by other members ofthe interdisciplinary group as well as by other qualified professionals as determined by the hospice;
   9. (I) Short-term inpatient care required for procedures necessary for pain control or acute or chronic symptom management provided in a participating hospice inpatient unit, or a participating hospital, or nursing facility (NF) that additionally meets the special hospice standards regarding staffing and patient areas;
   10. (J) Short-term inpatient respite care furnished as a means of providing respite for the individual’s family or other persons caring for the individual at home. The participating hospice inpatient unit, or a participant hospital, or NF must meet the special hospice standards regarding staffing and patient areas. areas.

   11. (K) Medical appliances and supplies in- (K) Medical appliances and supplies including all drugs and biologicals used pricluding all drugs and biologicals used primarily for the relief of pain and symptom marily for the relief of pain and symptom control related to the individual’s control related to the individual’s terminal terminal illness.

       1. 1. Appliances may include covered dura-

ble medical equipment as well as other selfhelu and oersonal comfort items related to the pal&ion or management of the patient’s terminal illness.

1. 2. Equipment is provided by the hospice

for use in the patient’s home while s/he is under hospice care.

1. 3. Medical supplies include those that are

part of the written plan of care;

1. (L) Home Health Aide Services Furnished by Certified Aides. Home health aides may provide personal care services and perform household services to maintain a safe and sanitary environment in areas of the home used by the patient. Examples ofthese services are: changing the bed linen or light cleaning and laundering essential to the comfort and cleanliness of the patient. Aide services must be provided under the general supervision of an RN. Home health aide services must be available and adequate in frequency to meet the needs of the patient, as defined in the plan of care;

   (Z/28/94) Judith K. Moriarty semtary Of state

1. (M) Homemaker services furnished to provide assistance in personal care, maintenance of a safe and healthy environment and services to enable the individual to carry out the treatment plan; and (NJ Physical therapy, occupational therapy and speech/language pathology services for purposes of symptom control or to enable the individual to maintain activities ofdaily living and basic functional skills. When provided, the services must be offered in a manner consistent with accepted standards of practice.
2. (6) The following services are not covered through the hospice program:
3. (A) Any services provided by inappro. priately qualified personnel;
4. (B) Anyserviceortreatment notlistedin the individual’s plan of care;
5. (C) Any service or treatment that is not directly related to pain control or palliation of the recipient’s terminal illness;
6. (D) Nurse’s aide services not under the supervision of an RN;
7. (E) Inpatient servxes beyond the boundaries of the inpatient cap; and
8. (F) Respite care over five (5) days per -~ calendar month.
9. (7) Reimbursement. Hospice services, as defined in this rule and provided by qualified providers, shall be reimbursed for dates of service beginning on or after May 15,1989. The reimbursement rate for hospice services includes all covered services related to the treatment ofthe terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of or working under arrangements made with the hospice. These activities would generally be performed by the physician serving as the medical director and the .. physician member of the hospice interdisciplinary group. Group activities would include participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care and establishment of governing policies. The costs for these services are included in the reimbursement rates for routine home care, continuous home care and inpatient respite care.

10. (A) A per-diem rate for each day on which hospice services are provided will be established based on the Title XVIII Medicare rate for the specific hospice based on the level of careprovided-

    1. 1. Routine home care;
    2. 2. Continuous home care. A minimum of eight (8) hours of continuous care must be provided during a twenty-four (24).hour period;

    3. 3. General inpatient care; and

       Judith K. Moriarty (Z/28/94) Secretary Of stm

       1. 4. Inpatient respite care. Reimbursement is limited to five (5) consecutive days per calendar month and to the mandatory inpatient day limit.

11. (B) Nursing Home Room and Board. Medicaid-eligible individuals residing in Medicaidcertified NFs who meet the hospice eligibility criteria may elect Medicaid hospice care services. In addition to the routine home care or continuous home care per-diem rates, an amount may be paid to the hospice to cover the nursing home room and board costs. The hospice will reimburse the nursing home. Room and board include the performance of personal care services that a caregiver would provide if the individual were at home. These services include assistance in the activities of daily living: washing and grooming, toil&g, dressing,, meal service, soeializmg (companionshlp, hobbies, and the like), administration of medication, maintaining the cleanliness of the resident’s bed and room and supervising and assisting in the use of durable medical equipment and prescribed therapies (forexample,rangeofmotionexercises, speech and language exercises).

    1. 1. There must be a written agreement

between the hospice and the nursing home under which the hospice takes full responsi. bility for the professional management of the individual’s hospice care and the nursing home agrees to provide room and board to the individual. The hospice and the nursing home will retain a copy of the agreement and one (1) copy must be on file at the Division of Medical Services.

1. 2. For purposes of the Medicaid hospice benefit. an NF can be considered the individual’s residence.
2. 3. Payment for NF room andboard willbe determined in accordance with rates estab. lished under section 1902iaY13) of the Social ,,, Security Act. (0 Phvsician Services. Medicaid will reimburse the hospice provider for certain physician services, such as direct patient care services, furmshed to individual patients by hospice employees and for physician services furnished under arrangements made by the hospice unless the patient care services were furnished on a volunteer basis. Medicaid will reimburse the hospice for attending physician services when the physician is employed by the hospice. These physician services will be reimbursed in accordance with Medicaid reimbursement policy for physician services based on the lower of the actual charge or the Medicaid maximum allowable amount for the specific service.

1. (D) Limitation on Payments for Inpatient Care. Payments to hospice providers for inpatient care must be limited according to the number of days of inpatient care furnished to 13 CSR 70-50 )

   m

Medicaid patients. During the twelve (12). month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed twenty percent (20%) of the aggregate total number of days of hospice care provided to all Medicaid recipients during that same period. This limitation is applied once each year, at the end of the hospice’s cap period (11/l-10/31). For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the hospice receives payment at a home care rate will not be counted as inpatient days. Any excess reimbursement will be refunded by the hospice. (8) Cost Sharing. Hospice services shall be exempt from these Medicaid cost-sharing requirements as may be otherwise applicable to a comparable service when provided other than as a hospice service. (9) General Regulations. This rule shall not encompass all of the general regulations of the Medicaid program. These regulations, however, shall be in effect for hospice services. Auth: sections 208.152, RSMo (Cum. SUPP. 1993),208.153, RSMo (Cum. Supp. 1991) and 208.201, RSMo (Supp. 19871.’ Emergency rule filed May 17, 1989, effective May 27, 1989, expired Sept. 13, 1989. Original rule filed May 17, 1989, effectiue Aug. 11, 1989. Amended: Filed June 18, 1991, effective Dec. 9, 1991. Amended: Filed Sept. 2, 1993, effeetiue April 9, 1994. *Original authority: 208.152, RSMo (19671, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978,1981,1986,1988,1990,1992,1993;208.153, RSMo (19671, amended 1973,1989,1990,1991; and 208.201, RSMo 11987). 13 CSR70-50-SOCIALSERVICES

M,SSO”R, DlVlSlON OF MEDICAL SERVICES HOSPICE ELECTION STATEMENT

records and/or

I understand my consent for the following

The above named services will be made available consisting of the Medical Director. with my attending

In accordance - Home private duty nursing - Ongoing

I understand origin, handicap

I understand life sustaining measures will be initiated.

I understand benefits related

I will also be eligible that I have the right in writing, at which

Date Hospice Election

tc b si b t MC DEPARTMENT

information to or from Hospice as required

that the hospice services should

Appropriate Nursing Care Dietary Counseling Medical Social Services Counseling Services Respite Care

physician.

with Medicaid law. the following

hospitalization

that the hospice or age. I acknowledge

that the goal for the hospice care given will be the relief of pain and symptom management

that as long as I remain eligible to my terminal

for regular Medicaid to change my mind at any time I will be eligible

to Begin

OF SOCIAL SERVICES

HOSWCE PROGRAM - REQUEST FOR SERVICE

named above provides they be needed

Patient Care Coordinator.

services are not covered:

in absence of a physical

when care needed no longer

named above will provide I have received a cbpy of the hospice’s

for Medicaid

condition as they are arranged

benefits time and for return

to act on this request.

physical, emotional in my care:

Trained Non-Medical Home Health Aide/Homemaker Ancillary Therapy Services Inpatient Services Medications Equipment Bereavement

as need is determined Medical Social Worker,

crisis of the patient. requires

its services to all persons without

and choose to receive hospice by the above named hospice.

for treatment or conditions to discontinue to regular Medicaid benefits and spiritual

Volunteers

for Pain and Symptom Control and Supplies Services

and directed by the Hospice and Counselor

inpatient setting.’

service policy.

not related

Hospice Medicaid for treatment and authorize

care to me and my

Services

interdisciplinary working

regard to

and that no extraordinary

care. I will be eligible

to my terminal benefits by indicating my wishes of my terminal

(Z/28/94)

of Medical Services

release of all medical

family. This is

Team

cooperatively

race, creed, national

for Medicaid

illness. I understand

illness.

Judith K. Moriarty Seeramy 0‘ Stats