Hospice Care — Coverage Criteria
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Rules governing Medicaid-covered hospice services in Alabama, including provider requirements, recipient eligibility, documentation, certification, and program administration for full-benefit Medicaid recipients who elect hospice care.
No material clinical or coverage changes in this revision.
Hospice Coverage Criteria and Clinical Eligibility
inv-01: General Eligibility and Documentation
Covered when ALL of the following are met
Medical certification must include specific clinical findings and supporting documentation (medical records, labs, x-rays, pathology). Hospice must retain medical records at least three years and failure to establish the hospice medical record as defined will result in denial.
Form 165 must be present for each election period; written election filed within two calendar days after hospice care begins; physician certification may be verbal initially but written certification required within regulatory timeframes; records retained for at least three years and available for audit/recoupment.
inv-02: Adult Failure to Thrive
Covered when ALL of the following are met
Measurements/observations must be within 180 days of certification/recertification. If enteral nutritional support is being continued, use measurements at initial certification and each recertification. At recertification, recumbent anthropometry (e.g., mid-arm circumference) may substitute for BMI with documentation why BMI could not be measured.
inv-03: Adult HIV Disease
Covered when ALL of the following are met
Documentation of listed supporting conditions (e.g., CNS lymphoma, untreated wasting, MAC bacteremia, PML, systemic lymphoma, visceral Kaposi's, renal failure without dialysis, cryptosporidium, toxoplasmosis) strengthens eligibility; absence of antiretroviral/chemotherapeutic therapy is a supporting factor. Recertification requires persistent viral load >100,000 plus KPS ≤ 50 and supporting conditions.
inv-04: Adult Pulmonary Disease
Covered when ALL of the following are met
If FEV1 not performed, clinical condition must support FEV1 <30%; recertification requires severe disabling dyspnea at rest plus hypoxemia/hypercapnia. Patients on non-emergent artificial ventilator support are excluded from pulmonary hospice eligibility.
inv-05: Alzheimer's Disease & Related Disorders
Covered when ALL of the following are met
FAST Stage 7 substantiates prognosis supporting six-month life expectancy; secondary conditions are considered separately and must be documented.
inv-06: Hospice Criteria — Adult Alzheimer's Disease & Related Disorders
Covered when ALL of the following are met
Secondary conditions related to the primary Alzheimer's diagnosis must be documented to support hospice eligibility.
inv-07: Hospice Criteria — Adult Stroke
Covered when BOTH of the following are present
Numeric weight and albumin thresholds must be documented; caloric counts or aspiration history support eligibility.
inv-08: Hospice Criteria — Adult Coma
Covered when ANY of the following sets are met
These findings support a terminal prognosis for coma of any etiology.
inv-09: Hospice Criteria — Adult ALS
Patient must fulfill (i), (ii), or (iii)
Neurologist examination within three months is required to confirm diagnosis and assist prognosis.
Multiple clinical parameters demonstrating rapid decline and nutritional failure required.
Case-by-case review for other complications with appropriate medical justification.
inv-10: ALS Recertification Criteria
For recertification BOTH required
Neurologist exam and documentation of progression within the recertification interval required to support continued terminal prognosis.
inv-11: Hospice Criteria — Adult Cancer
Covered when ANY of the following are present
Applies to initial certification and recertification; supporting objective documentation required.
inv-12: Hospice Criteria — Adult Heart Disease
Covered when ALL of the following are present
Additional supportive factors (e.g., EF ≤20%, history of arrest, refractory angina) may provide further evidence of terminal prognosis. The policy requires prior optimal treatment unless contraindicated or declined.
inv-13: Hospice Criteria — Adult Liver Disease
Covered when BOTH of the following are present
Other supportive factors (malnutrition, muscle wasting, hepatocellular carcinoma, refractory hepatitis B/C) may strengthen eligibility.
inv-14: Hospice Criteria — Adult Renal Disease
Covered when specific numeric renal thresholds are met
Both criteria must be present for acute renal failure eligibility; patient on dialysis is excluded.
All three criteria must be present for chronic renal failure eligibility; dialysis disqualifies the patient for hospice under this policy.
inv-15: Covered Services and Levels of Care
Covered hospice services and reimbursement conditions
Core services (nursing, physician, social services, counseling) must routinely be provided directly by hospice employees; supplemental services may be contracted.
Medicaid hospice payment rates conform to CMS methodology and are prospectively determined per diem amounts; drugs related to the terminal illness and Hospice Palliative Drug List (HPDL) items are included in the per diem and not reimbursed through the Medicaid Pharmacy Program; if a nursing‑home resident elects hospice, Medicaid pays hospice 95% of the nursing home rate in lieu of direct nursing home payment.
Alabama Medicaid hospice services are not available for individuals who are pursuing aggressive (life‑prolonging or curative) treatment. The policy defines "aggressive treatment" as care intended to be life‑prolonging or curative rather than palliative and which would alter the natural course of the terminal illness; such individuals must not be certified for hospice services. Providers must ensure recipients meet the medical and financial criteria for hospice and document eligibility before certification and at each recertification period. Failure to establish and maintain required documentation or to show continued terminal status may result in denial or recoupment of payments. (See required Form 165 and physician certification rules.)
Providers must obtain physician certification that the recipient is terminally ill with a life expectancy of six months or less if the disease follows its normal course and must maintain medical records that support that certification (medical records, labs, x‑rays, pathology). Certifications are subject to review and audit; absence of supporting documentation of progression or rapid decline is a listed reason for denial.
When a recipient elects hospice, they must waive rights to other Medicaid services related to the treatment of the terminal condition for the duration of the hospice election, except for services: (a) provided by the designated hospice, (b) provided by another hospice under arrangements made by the designated hospice, or (c) provided by the attending physician who is not an employee of the hospice and is not compensated by the hospice. Medicaid services not related to the hospice primary diagnosis are not waived.
Specific diagnostic exclusions are stated elsewhere in the policy: for example, recipients on dialysis are explicitly excluded from hospice eligibility for renal disease, and patients on non‑emergent artificial ventilator support are excluded for pulmonary disease criteria. Providers must verify these exclusions before certifying hospice and document any contraindicating treatments in the medical record.
For renal disease, hospice eligibility requires meeting strict numeric thresholds for kidney function. The policy specifies that acute renal failure eligibility requires both (I) creatinine clearance <10 cc/min (<15 cc/min for diabetes) and (II) serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetes); chronic renal failure requires those thresholds plus GFR <30 ml/min. Importantly, patients on dialysis are excluded from hospice eligibility. Providers must document the required laboratory and renal function data at initial certification and recertification.
Failure to meet these numeric criteria or documentation requirements is a listed reason for denial; providers should verify dialysis status and include recent lab results and GFR/CrCl calculations in the hospice medical record.
When a beneficiary elects hospice, they must waive rights to Medicaid services that are related to the treatment of the terminal condition for the duration of the election, except for services provided by the designated hospice, services provided by another hospice under arrangements made by the designated hospice, or services provided by the individual's attending physician if that physician is not an employee of the designated hospice and does not receive compensation from the hospice. Medicaid covered services that are not related to the hospice recipient's terminal illness are not waived.
Providers must ensure beneficiaries complete the hospice election and that the hospice documents the election and associated physician certification (Form 165) in the medical record; these election and waiver rules are part of eligibility and affect which Medicaid services remain payable during the hospice election period.
Alabama Medicaid lists multiple conditions and documentation failures that are considered not medically necessary for hospice coverage. Primary triggers for denial include: not meeting the specific medical criteria for the listed diagnosis; absence of supporting documentation showing progression or rapid decline; failure to document terminal status of life expectancy ≤ six months; and lack of full Medicaid benefit eligibility.
Diagnosis‑specific examples of noncoverage include: HIV patients who are receiving antiretroviral, chemotherapeutic, or prophylactic drug therapy specifically related to HIV disease; pulmonary disease patients who are on non‑emergent artificial ventilator support; and renal patients who are receiving dialysis. For coma, patients must meet coma criteria (three or more listed findings on day three or after) or they will be considered not medically necessary for hospice under this rule.
Providers must include objective clinical evidence (e.g., recent labs, functional scales, documented rapid progression, neurologist exam for ALS within three months) in the medical record to support hospice certification; absence of such documentation is repeatedly cited as a reason for denial across disease categories.
Do not impose co-payments or bill patients for Medicaid-covered hospice services
Co-payments may not be imposed and the patient or responsible party shall not be billed in full or in part for any service reimbursed under any Medicaid hospice service component; payment by Medicaid is payment in full.
- Do not bill beneficiaries for Medicaid-covered hospice services; only non‑covered services may be billed to the individual.
- For dually eligible recipients, bill Medicaid only for the limited coinsurance amounts and percentages allowed (per policy limits).
Key Clinical Thresholds and Coding-related Values
Required Provider Documentation, Filing, and Billing Actions
Submit physician certification and Form 165 with supporting clinical evidence
Obtain and maintain physician certification of terminal illness and the Medicaid Hospice Election and Physician's Certification (Form 165) plus supporting clinical documentation (medical records, labs, x-rays, pathology) as part of the permanent medical record; submit required hospice election and certification documentation to Medicaid for coverage and audit purposes.
File Form 165 within required timeframe and retain for each election period
File the written Medicaid Hospice Election and Physician's Certification (Form 165) with the hospice within two calendar days after hospice care begins; Form 165 must be present for each election period and may be used for Medicare/Medicaid dual eligibles.
Hospice reimbursement follows CMS per‑diem methodology by level of care
Medicaid hospice payment rates and reimbursement follow the CMS methodology; payment is made to the hospice as prospectively determined per diem amounts by level of care (routine home, continuous home, inpatient respite, general inpatient).
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No provider action specified for this inventory item.
Document optimal heart failure medical therapy prior to certification
For heart failure hospice certification, document that the patient is already optimally treated with beta blockers, diuretics, and vasodilators (ACE inhibitors or ARBs) unless documented contraindication, treatment failure, or patient refusal.
Medications for terminal illness included in hospice per diem (not reimbursed via pharmacy)
Drugs related to the recipient's terminal illness and drugs on the Hospice Palliative Drug List (HPDL) are included in the hospice per diem and will not be reimbursed through the Medicaid Pharmacy Program.
- HPDL is available on the agency website at www.medicaid.alabama.gov
Maintain physician certification and complete permanent medical record content
Obtain physician certification of terminal illness with specific clinical findings and supporting medical documentation; maintain a permanent medical record that includes physician certifications, services provided, recipient election statements, interdisciplinary plan of care and updates, advance directive documentation, and Form 165 for each election period.
Be Medicare‑certified, enroll with Medicaid, and verify recipient eligibility
Ensure hospice provider enrollment and Medicare certification; verify the recipient's Medicaid eligibility and submit required hospice election and physician certification documentation to Medicaid as part of enrollment and coverage verification.
Document ≤ six‑month prognosis and disease‑specific staging/metrics
Document a medical prognosis of life expectancy six months or less and include disease‑specific staging or objective metrics (e.g., FAST level 7 with at least 4 of 6 substages for Alzheimer's) and other supporting clinical evidence required for certification and recertification.
Follow change‑of‑hospice, recordkeeping, and audit cooperation procedures
When changing designated hospice, file a signed statement (names of old and new hospices and effective date) and provide copies to the hospice and Alabama Medicaid; maintain complete and accurate medical and fiscal records and furnish requested claims information for audits and program monitoring.
- Retain medical records for at least three years
Risk of recoupment if medical necessity or documentation requirements are not met
Alabama Medicaid will initiate recoupment of payment when state and federal medical necessity and eligibility requirements are not met; failure to establish the hospice medical record as defined will result in denial and possible recoupment.
Denial risk for missing clinical criteria, progression evidence, or eligibility
Services may be denied if the patient does not meet the specific medical criteria, lacks documentation of progression or decline, fails to document terminal status of six months or less, or is not eligible for full Medicaid benefits.
Common reasons for denial (documentation, timelines, diagnosis‑specific failures)
Denials can be triggered by: not meeting diagnosis‑specific criteria; absence of supporting documentation of progression or rapid decline; failure to document terminal status of six months or less; missing physician signatures or required timelines; and, for renal disease, being on dialysis.
Revocation forfeits remaining election days and requires submission of revocation form
If an individual revokes the hospice election, any days remaining in that election period are forfeited and the hospice must provide Alabama Medicaid a copy of the revocation form; upon revocation the recipient resumes Medicaid coverage of benefits waived while on hospice.
Definitions and Background
Hospice care provides palliative, comfort‑focused services for individuals with a medical prognosis of six months or less if the illness follows its normal course. The program emphasizes symptom control, pain management, and comprehensive interdisciplinary care rather than curative treatment. Eligibility is determined by documented clinical findings, disease‑specific staging or objective measures, a physician certification of terminal illness, and a written plan of care maintained in the medical record.
Providers must obtain and retain required documentation (including the hospice election/physician certification form) and follow Medicare certification and Medicaid provider requirements; failure to maintain the defined record elements can result in denial or recoupment.
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