DAR File No. 39142

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-14A

Hospice Care

Notice of Proposed Rule

(Amendment)

DAR File No.: 39142
Filed: 02/17/2015 08:09:00 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to implement recommendations made by the Office of Inspector General (OIG) following an audit of the Medicaid Hospice Care program in 2014.

Summary of the rule or change:

This amendment requires an independent physician review when a hospice patient reaches 12 or more months of consecutive hospice care. It also specifies criteria for prior authorization as it relates to hospice election periods, and prohibits "debility" and "adult failure to thrive" as sole primary terminal diagnoses.

State statutory or constitutional authorization for this rule:

• 42 U.S.C. 1396d(o)
• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

Savings to the state budget may coincide with these new eligibility requirements. Nevertheless, there is not enough data to estimate the fiscal impact at this time.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid recipients.

small businesses:

Some costs to small businesses may coincide with these new eligibility requirements. Nevertheless, there is not enough data to estimate the fiscal impact at this time.

persons other than small businesses, businesses, or local governmental entities:

Some costs to hospice care providers and to hospice care recipients may coincide with these new eligibility requirements. Nevertheless, there is not enough data to estimate the fiscal impact at this time.

Compliance costs for affected persons:

Some costs to a hospice care provider or to a hospice care recipient may coincide with these new eligibility requirements. Nevertheless, there is not enough data to estimate the fiscal impact at this time.

Comments by the department head on the fiscal impact the rule may have on businesses:

This amendment may have some effect on businesses related to hospice care in that it changes eligibility requirements for hospice care recipients, but current data is insufficient to estimate the fiscal impact at this time.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

03/31/2015

This rule may become effective on:

04/07/2015

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-14A. Hospice Care.

R414-14A-3. Client Eligibility Requirements.

(1) A client who is terminally ill may obtain hospice care pursuant to this rule.

(2) A client's certification of a terminal condition required for hospice eligibility must be based on a face-to-face assessment by a physician conducted no more than 90 days prior to the date of enrollment.

(3) A client dually enrolled in Medicare and Medicaid must elect the hospice benefit for both Medicare and Medicaid. The client must receive hospice coverage under Medicare. Election for the Medicaid hospice benefit provides the client coverage for Medicare co-insurance and coverage for room and board expenses while a resident of a Medicare-certified nursing facility, intermediate care facility for people with an intellectual disability (ICF/ID), or freestanding hospice facility.

(4) Primary diagnoses of "debility" and "adult failure to thrive" do not meet eligibility criteria for Medicaid hospice care if the patient does not have a least one other more definitive co-occurring principle terminal diagnosis.

 

R414-14A-6. Hospice Election.

(1) A client who meets the eligibility requirement for Medicaid hospice must file an election statement with a particular hospice. If the client cannot cognitively make informed health care decisions or is under 18 years of age, the client's legally authorized representative may file the election statement.

(2) Each hospice provider designs and prints his own election statement. The election statement must include the following:

(a) identification of the particular hospice that will provide care to the client;

(b) the client's or representative's acknowledgment that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the client's terminal illness;

(c) for adult clients, acknowledgment that the client waives certain Medicaid services as set forth in Section R414-14A-9;

(d) acknowledgment that the client or representative may revoke the election of the hospice benefit at any time in the future and therefore become eligible for Medicaid services waived at the time of hospice election as set forth in Section R414-14A-8; and

(e) the signature of the client or representative.

(3) The effective date of the election may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement

(4) An election to receive hospice care remains effective through the initial election period and through the subsequent election periods without a break in care as long as the client:

(a) remains in the care of a hospice;

(b) does not revoke the election; and

(c) is not discharged from the hospice.

(5) The hospice provider must notify the Department at the time a Medicaid client selects the hospice benefit, including selecting the hospice provider under a change of designated hospice. The notification must include a copy of the hospice election statement and the physician's certification of terminal illness for hospice care. Authorization for reimbursement of hospice care begins no earlier than the date notification is received by the Department for an eligible Medicaid client, except as provided in Section R414-14A-20.

(6) Subject to the conditions set forth in this rule, a client may elect to receive hospice care during one or more of the following election periods:

(a) an initial 90-day period;

(b) a subsequent 90-day period; or

(c) an unlimited number of subsequent 60-day periods.

(7) The Department may only grant prior authorization for hospice care in alignment with the election periods defined in Subsection R414-14A-6(6).

 

R414-14A-13. Extended Hospice Care.

(1) [Clients]Adult patients who accumulate 12 or more consecutive months of hospice benefits are subject to an independent utilization review by a physician [with expertise in end-of-life and hospice care selected by the Department.]who is not affiliated with the hospice agency. Independent reviews are subsequently required every 12 months thereafter if the patient continues to receive extended hospice care. 12 consecutive months means 12 months in a row wherein a hospice provides Medicaid hospice care during any portion of each month.

(2) If Medicare determines that a patient is no longer eligible for Medicare reimbursement for hospice services, the patient will no longer be eligible for Medicaid reimbursement for hospice services. Providers must immediately notify Medicaid upon learning of Medicare's determination. Medicaid reimbursement for hospice services will cease the day after Medicare notifies the hospice provider that the client is no longer eligible for hospice care.

 

R414-14A-20. Notification and Prior Authorization Grace Periods.

(1) If a new patient is already Medicaid eligible upon admission to hospice care, the hospice provider must submit a prior authorization request form to the Department in order to receive reimbursement for hospice services it renders, except in the following circumstances:

(a) [d]During weekend, holidays, and after regular Department business hours, a hospice provider may begin service to a new Medicaid hospice enrollee, including covering room and board, or initiate a different hospice care requiring prior authorization for a grace period up to ten calendar days before notifying the Department;

(b) [b]Before the end of the ten calendar day grace period, the hospice provider must complete and submit the prior authorization request form to the Department in order to receive reimbursement for hospice services it renders;

(c) [i]If the hospice provider does not submit the prior authorization request form timely, the Department will not reimburse the provider for the care that it renders before the date that the form is received.

(d) The hospice provider must complete and submit with the prior authorization request, the form for independent physician review when an adult patient reaches 12 consecutive months in hospice care. The Department shall deny the prior authorization request if the provider does not include this form with the other required documents, or if this form does not indicate the patient meets ongoing eligibility criteria for Medicaid hospice care.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 22, 2013]2015

Notice of Continuation: June 17, 2014

Authorizing, and Implemented or Interpreted Law: 26-1-4.1; 26-1-5; 26-18-3