CurrentAlabama MedicaidPolicy N/A

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.

Policy Summary

PayerAlabama Medicaid

PolicyHospice Care — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 13, 2021

Last ReviewSep 13, 2021

Next Review DateN/A

Key ActionObtain and file a completed hospice election (Form 165) and physician certification with supporting clinical documentation for each election period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsprognosis threshold

Form 165required election form

3 yrsrecord retention

<22failure to thrive BMI

<30%

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Hospice Coverage Criteria and Clinical Eligibility

inv-01: General Eligibility and Documentation

Covered when ALL of the following are met

General Hospice Eligibility: Full Medicaid eligibility for benefits AND physician certification that the recipient is terminally ill with a medical prognosis of life expectancy six months or less AND hospice services are medically necessary for palliation or symptom and pain management related to the terminal illness AND a written interdisciplinary plan of care is established and maintained AND required documentation is present (including Medicaid Hospice Election and Physician's Certification, Form 165 for each election period).

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.

Provider Actions - Enrollment, Documentation, and Submission: Hospice provider must be Medicare-certified, participate in Medicare, verify recipient's Medicaid eligibility, obtain and maintain physician certifications and supporting medical documentation, and submit required election/certification documentation (Form 165) for each election period to Alabama Medicaid.

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

Failure to Thrive Initial/Recertification: Nutritional impairment with Body Mass Index (BMI) below 22 kg/m2 AND significant disability demonstrated by Karnofsky or Palliative Performance Scale value less than or equal to 40%.BMI < 22 kg/m2; KPS/PPS ≤ 40%

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

HIV Initial Certification: CD4+ count less than 25 cells/mcL OR persistent viral load greater than 100,000 copies/ml PLUS decreased performance status (Karnofsky Performance Status ≤ 50).CD4 < 25 cells/mcL OR viral load >100,000 plus KPS ≤ 50

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

Pulmonary Disease Initial Certification: (i) Severe chronic lung disease documented by FEV1 after bronchodilator less than 30% of predicted with disabling dyspnea at rest poorly responsive to bronchodilators; AND (ii) progression documented by two or more episodes of pneumonia or respiratory failure requiring ventilatory support within the last six months OR serial decrease in FEV1 >40 ml/year for past two years; AND (iii) hypoxemia at rest on room air with ABG PO2 ≤ 59 mmHg or oxygen saturation ≤ 89% at rest, or hypercapnia with PCO2 ≥ 50 mmHg.FEV1 < 30% predicted; PO2 ≤ 59 mmHg or O2 sat ≤ 89% or PCO2 ≥ 50 mmHg

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

Alzheimer's Disease Eligibility: Documentation of FAST (Reisberg Functional Assessment Staging) Scale level equal to 7 with at least 4 of the 6 substage FAST indicators present within six months prior to hospice election AND documentation of specific secondary condition(s) related to Alzheimer's disease (e.g., contractures, pressure ulcers, recurrent UTI, dysphagia, aspiration pneumonia).FAST Stage 7 with ≥4 of 6 substage indicators

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

Alzheimer's Hospice Criteria: (i) FAST scale level equal to 7 with documentation of at least 4 of 6 substage FAST indicators under level 7; AND (ii) documentation of specific secondary condition(s) related to Alzheimer's disease (examples: contractures, pressure ulcers, recurrent UTI, dysphagia, aspiration pneumonia).FAST stage 7 with ≥4 substages

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

Stroke Eligibility: (i) Palliative Performance Scale (PPS) consistent with being mainly bedbound, extensive disease, needing assistance with self-care, reduced intake, or altered consciousness (PPS less than or equal to levels indicating severe decline); AND (ii) inability to maintain hydration and caloric intake as shown by one or more of: weight loss >10% in 6 months or >7.5% in 3 months, serum albumin <2.5 gm/dl, current history of pulmonary aspiration unresponsive to speech-language pathology interventions, documented inadequate caloric/fluid intake, or severe dysphagia preventing sustenance when patient declines/artificial nutrition and hydration is not provided.Weight loss >10% in 6 months or >7.5% in 3 months; serum albumin <2.5 gm/dl

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

Coma Eligibility: Comatose patients who have any three of the following findings on day three of coma or thereafter: abnormal brain stem response; absent verbal response; absent withdrawal response to pain; increase in serum creatinine greater than 1.5 mg/dl.3 of listed findings on/after day 3 of coma

These findings support a terminal prognosis for coma of any etiology.

inv-09: Hospice Criteria — Adult ALS

Patient must fulfill (i), (ii), or (iii)

ALS Pathway i - Respiratory Failure: Within the prior 12 months: vital capacity (VC) less than 30% of normal AND continuous dyspnea at rest AND hypoxemia at rest on room air (ABG PO2 ≤ 59 mmHg or oxygen saturation ≤ 89%) AND patient declines artificial ventilation.VC <30%; PO2 ≤59 mmHg or O2 sat ≤89%

Neurologist examination within three months is required to confirm diagnosis and assist prognosis.

ALS Pathway ii - Rapid Progression plus Nutritional Impairment: Rapid progression of ALS within 12 months (e.g., independent ambulation to wheelchair/bed bound; normal to barely intelligible/unintelligible speech; normal to pureed diet; independence to major assistance in ADLs) AND critical nutritional impairment (oral intake insufficient to sustain life AND unintentional progressive weight loss >10% over preceding six months).>10% unintentional weight loss over 6 months; documented rapid functional decline

Multiple clinical parameters demonstrating rapid decline and nutritional failure required.

inv-10: ALS Recertification Criteria

For recertification BOTH required

ALS Recertification: (i) Critically impaired breathing capacity as evidenced by continuous dyspnea at rest and hypoxemia at rest on room air (ABG PO2 ≤ 59 mmHg or oxygen saturation ≤ 89%) with patient declining artificial ventilation; AND (ii) rapid progression of ALS plus at least one life‑threatening complication (e.g., two or more aspiration pneumonias, pyelonephritis, sepsis).PO2 ≤59 mmHg or O2 sat ≤89% plus complication presence

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

Cancer Eligibility: (i) Documentation of metastasis or final disease stage with evidence of progression (worsening clinical status, symptoms, signs and/or laboratory results); OR (ii) progression from an earlier stage to metastatic disease with either continued decline despite aggressive treatment OR the patient declines further disease‑directed therapy.Documented metastasis or progression

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

Heart Disease Eligibility: (i) Patient is optimally treated with beta blockers, diuretics, and vasodilators (ACE inhibitors or ARBs) unless contraindicated, there is documented treatment failure, or the patient voluntarily declines such therapy; AND (ii) significant symptoms of recurrent heart failure at rest consistent with NYHA Class IV (symptoms present at rest and inability to carry on any physical activity without symptoms).NYHA Class IV; optimal medical therapy unless documented exceptions

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

Liver Disease Eligibility: (i) Documentation of active decline/progression evidenced by worsening clinical status, symptoms, signs, or laboratory results (examples include recurrent/intractable infections, progressive inanition, dyspnea with increasing RR, refractory nausea/vomiting, intractable diarrhea, pain requiring increasing major analgesics, ascites, edema, weakness, change in consciousness, worsening gas exchange, increasing LFTs or sodium abnormalities); AND (ii) presence of end‑stage liver disease with at least one of: refractory ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, refractory hepatic encephalopathy, or recurrent variceal bleeding despite intensive therapy.One listed end‑stage sign plus evidence of active decline

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

Renal Disease Eligibility - Acute: Acute renal failure: both (I) creatinine clearance less than 10 cc/min (less than 15 cc/min for diabetes) AND (II) serum creatinine greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes).CrCl <10 cc/min (<15 if diabetes); SCr >8.0 mg/dl (>6.0 if diabetes)

Both criteria must be present for acute renal failure eligibility; patient on dialysis is excluded.

Renal Disease Eligibility - Chronic: Chronic renal failure: (I) creatinine clearance less than 10 cc/min (less than 15 cc/min for diabetes) AND (II) serum creatinine greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes) AND (III) glomerular filtration rate (GFR) less than 30 ml/min.GFR <30 ml/min plus CrCl/SCr thresholds

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

Covered Hospice Services: Nursing care; medical social services; physician services; counseling services; short‑term inpatient care; medical appliances and supplies including drugs and biologicals; home health aide and homemaker services; physical therapy, occupational therapy, and speech‑language pathology; nursing home room and board.

Core services (nursing, physician, social services, counseling) must routinely be provided directly by hospice employees; supplemental services may be contracted.

Levels of Care and Payment Rules: Routine home care; Continuous home care (for crisis periods when predominately skilled nursing care is required to palliate/manage acute symptoms; minimum 8 hours per day; hourly reimbursement up to 24 hours); Inpatient respite care (intermittent, non‑routine, maximum five consecutive days); General inpatient care (for pain control or acute/chronic symptom management).Continuous home care minimum 8 hours/day; Inpatient respite max 5 consecutive days; total inpatient days ≤20% of aggregate hospice days (Nov 1–Oct 31)

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.

Billing Rule

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

inv-22: BMI threshold for adult failure to thrive — < 22 kg/m2

BMI threshold (Adult Failure to Thrive)BMI < 22 kg/m2

Measurement timingBMI and disability measurements must be within 180 days of certification/recertification

Context of useApplies when patient is declining or not responding to enteral/parenteral nutritional support

inv-23: FEV1 threshold for advanced pulmonary disease — < 30% of predicted after bronchodilator

FEV1 threshold (Advanced Pulmonary Disease)FEV1 (post-bronchodilator) < 30% of predicted

Supporting requirementDisabling dyspnea at rest poorly responsive to bronchodilators and decreased functional capacity

Required Provider Documentation, Filing, and Billing Actions

Prior Authorization

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.

Prior Authorization

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.

Note

Hospice reimbursement follows CMS per‑diem methodology by level of care

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.

inv-48: Hospice — definition and Medicare-certification reference

Definition of HospiceA public agency or private organization primarily engaged in providing care to terminally ill individuals that meets Medicare conditions of participation and has a valid Medicaid provider agreement

Interdisciplinary team requirementHospice must include at minimum one physician, one registered nurse, one social worker, and one pastoral or other counselor

Election period structureElection periods: initial 90 days; subsequent 90 days; subsequent 60 days; unlimited subsequent 60‑day extensions