Coverage Policies

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Hospice services require pre-authorization and must be provided according to the pre-authorized treatment plan.

1)    Eligibility:

In order to be eligible for coverage under the member’s hospice benefit, the attending physician must certify that the individual’s medical prognosis is that his/her life expectancy is six months or less if the terminal illness runs the expected course. The attending physician must have examined the member within 14 calendar days of request for authorization.  

a)    If a member’s prognosis improves substantially and the member’s life expectancy exceeds six months, coverage for hospice care will be re-evaluated and could cease.

b)    To be eligible for hospice care, a member must have a personal caregiver for support.  Hospice is not a substitute for personal care.

c)     Hospice services are intended to provide palliative care.  Admission into a hospice program does not mean that care is being withdrawn, but does mean that care designed to be curative or life-prolonging is no longer intended.  Hospice provides treatments necessary for comfort, to improve function, or to alleviate pain.

i)       The following types of services are considered to be compatible with hospice care (not an all-inclusive list):

(1)  Radiation therapy for the purposes of relieving pain, for example, of a bony metastasis

(2)  Medication for pain, regardless of route

(3)  Medication for nausea, regardless of route

(4)  Surgical procedures to decompress a viscus, if required for comfort

ii)     The following types of services are considered to be attempts at cure or prolongation of life, and are not compatible with hospice care (examples only, not an all-inclusive list):

(1)  Cancer chemotherapy

(2)  Radiation therapy other than focal treatment to relieve pain

(3)  Total parenteral nutrition

(4)  Invasive procedures for provision of nutrition, including placement of feeding tubes of any kind.

2)    Hospice services:

a)    Counseling services are an integral part of hospice care.  These counseling services 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 the member to adjust to the member’s approaching death.  Counseling services for family members for up to six months after death are included.

b)    Home hospice is paid on a per diem basis.  This per diem payment covers all outpatient services related to care for the terminal disease, including medications, durable medical equipment, supplies, skilled nursing services, and aide services.  The exceptions are radiation therapy and services related to use of a pain pump, which are paid separately.

c)     Inpatient hospice is available for patients who develop symptoms that cannot be controlled in the home.  This may include pain that requires frequent changes in therapy to determine appropriate dosing, or intractable vomiting.  Once the patient is stabilized enough that symptoms can be controlled on an outpatient basis, the patient should return home with hospice. 

3)    Billing: 

a)    QualChoice recognized revenue codes for hospice services.  HCPCS codes will not be accepted.

Codes Used In This BI:

Revenue codes 0651, 0652, 0655 and 0656

See your plan documents for the number of days of hospice care allowed.

Hospice care focuses on controlling pain and other symptoms of illness so patients remain as comfortable as possible near the end of life.  Hospice care most often takes place at home, but can also be provided in special in-patient hospice facilities.

Considered to be the model for quality, compassionate care for people facing a life-limiting illness or injury, hospice care involves a team-oriented approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient`s needs and wishes. Support is provided to the patient`s loved ones as well.  At the center of hospice and palliative care is the belief that each of us has the right to die pain-free and with dignity, and that our families will receive the necessary support to allow us to do so.

The interdisciplinary hospice team:

§  Manages the patient’s pain and symptoms;

§  Assists the patient with the emotional and psychosocial and spiritual aspects of dying;

§  Provides needed drugs, medical supplies, and equipment;

§  Coaches the family on how to care for the patient;

§  Delivers special services like speech and physical therapy when needed;

§  Makes short-term inpatient care available when pain or symptoms become too difficult to manage at home; and

§  Provides bereavement care and counseling to surviving family and friends.

Addendum:

1)    Effective 01/01/2017: Noted exception for CHI members for not requiring pre-authorization and life expectancy of 12 months or less.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.