ModifiedHealth-New-EnglandPolicy UM1047POL

Hospice and Palliative Care- Medical Policy

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Governs medical necessity and authorization requirements for hospice and palliative care delivered in home or facility settings, including routine, continuous, intermittent, inpatient, and respite care. Applies to Health New England Commercial and Medicaid (BeHealthy) members; does not apply to Medicare.

Policy Summary

PayerHealth-New-England

PolicyHospice and Palliative Care- Medical Policy

Policy CodePolicy UM1047POL

Change TypeMinor criteria changes

Effective DateDecember 1, 2026

Next Review DateNot specified

Key ActionFor services subject to prior authorization, submit clinical evidence demonstrating that the patient meets the applicable criteria.

SourceLink

POLICY UPDATE CHANGES

The policy implementation history identifies minor criteria changes made in June 2026.

References were updated in June 2026.

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ModifiedHealth-New-EnglandPolicy UM1047POL

Hospice and Palliative Care- Medical Policy

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Sign up for Health-New-England Policy UM1047POL alerts

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Policy Summary

PayerHealth-New-England

PolicyHospice and Palliative Care- Medical Policy

Policy CodePolicy UM1047POL

Change TypeMinor criteria changes

Effective DateDecember 1, 2026

Next Review DateNot specified

Key ActionFor services subject to prior authorization, submit clinical evidence demonstrating that the patient meets the applicable criteria.

SourceLink

POLICY UPDATE CHANGES

The policy implementation history identifies minor criteria changes made in June 2026.

References were updated in June 2026.

≤6 monthsHospice prognosis

8 hoursContinuous-care minimum

>50%Nursing share of continuous care

5 daysRespite duration

No PAMedicaid prior authorization

8 codesListed services requiring prior authorization

Medical Necessity and Covered Levels of Care

Routine or ongoing hospice care in the home

Covered as medically necessary when ALL of the following are met:

Eligibility and care requirements

All required criteria
- The primary care physician or attending practitioner determines that hospice care is reasonable and medically necessary for the terminally ill member and certifies a life expectancy of 6 months or less.Life expectancy ≤ 6 months
- The member is functionally homebound.
- The member or appointed designee elects or continues to elect hospice care.
- The plan of care is established and periodically reviewed by the attending physician, hospice medical director, and hospice interdisciplinary care group.
- Services are reasonable and necessary for management and palliation of the member's terminal illness and related conditions.
- A willing and capable caregiver is present in the member's home to assist the member.
- Services are provided by a certified or accredited hospice agency with care available 24 hours per day, 7 days per week.24 hours/day, 7 days/week

Continuous home hospice care

Covered as medically necessary when ALL routine-care criteria and both additional criteria are met:

Continuous home hospice requirements

All criteria for routine or ongoing hospice care in the home are met.
See the routine home hospice criteria.
Crisis and home-maintenance requirements
- The member is experiencing a period of crisis requiring continuous care that is predominantly nursing care to manage acute medical symptoms or achieve palliation.
- Continuous care is necessary to maintain the member at home.
- At least 8 hours of nursing and home health aide care are required in the applicable 24-hour period, which begins and ends at midnight; the care hours do not need to be continuous.≥ 8 hours per 24-hour period

Intermittent palliative care services in the home

Covered as medically necessary when ALL of the following are met:

Intermittent palliative care requirements

Services are provided under a plan of care established by and periodically reviewed by a physician.
Services are medically necessary and reasonable based on the member's condition and accepted standards of clinical practice.
Services are an integral part of treatment of the member's medical condition and associated symptoms.

Facility-based hospice and palliative care

Covered as medically necessary when ALL of the following are met:

Facility-based care requirements

The member requires either
- Palliative care for a serious, complex, and often terminal illness.
- Hospice care, with certification that the member has a life expectancy of 6 months or less.Life expectancy ≤ 6 months
The physician and/or interdisciplinary team determines that care is reasonable and medically necessary for management and palliation of the illness and related conditions.
The member requires pain control or symptom management that cannot feasibly be provided in another setting, such as frequent skilled nursing interventions on all three shifts directed toward pain control and symptom management.

Inpatient respite care

Covered as medically necessary when ALL of the following are met:

Inpatient respite requirements

The member meets the criteria for home-based hospice care.
The physician or interdisciplinary team documents that family members, enrollees, or other primary caregivers need relief from care duties.
Caregiver relief must be documented.
Respite care is short-term inpatient care and is not residential or custodial care.
The respite stay is no more than five consecutive days per episode.Up to 5 consecutive days per episode

Medicare members and Medicare Advantage hospice are outside the scope of this policy. Medicare Advantage hospice is paid by Medicare fee-for-service under the hospice benefit provisions; refer to HNE’s Hospice Services Payment Policy.

Inpatient respite care is short-term inpatient care intended to relieve primary caregivers. It is not covered under the respite-care criteria when provided as residential or custodial care; approved respite care is limited to up to five consecutive days per episode.

A service or supply may meet the policy’s medical-necessity criteria but still be excluded from coverage or payment under the member’s benefit program. If the policy conflicts with the member’s benefits, the benefit program governs.

Authorization Codes and Key Service Thresholds

Codes requiring prior authorizationHCPCS

G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
G0155	Services of clinical social worker in home health or hospice settings, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
G0157	Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
G0158	Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes.
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.

Codes not requiring prior authorizationHCPCS

T2042	Hospice routine home care; per diem (MassHealth only).
T2043	Hospice continuous home care; per hour (MassHealth only).
T2044	Hospice inpatient respite care; per diem (MassHealth only).
T2045	Hospice general inpatient care; per diem (MassHealth only).
T2046	Hospice long-term care, room and board only; per diem (MassHealth only).

Continuous Home Care Minimum

Minimum careAt least 8 hours of nursing and home health aide care are required in a 24-hour period.

24-hour periodThe care period begins and ends at midnight.

ContinuityThe required care hours do not need to be continuous.

Continuous-Care Nursing Proportion

Nursing proportionMore than 50% of continuous-care hours must be nursing care provided by an R.N. or L.P.N.

Crisis careContinuous home care requires a period of crisis requiring predominantly nursing care to manage acute medical symptoms or achieve palliation.

Authorization, Documentation, and Denial Risks

Note

Commercial Criteria Apply

For Commercial members, apply the medical-necessity criteria under the Policy section of this medical policy when evaluating hospice and palliative care services.

Billing Rule

Medicaid: No Prior Authorization

Medicaid members do not require prior authorization for hospice services. Providers must follow the applicable Massachusetts hospice-services regulations for service delivery and billing.

Massachusetts hospice services regulations: https://www.mass.gov/doc/hospice-services-regulations/download

Note

Medicare Is Outside This Policy's Scope

Hospice and Palliative Care Context

Hospice care is interdisciplinary medical, psychological, and spiritual support for individuals and families facing a life-limiting illness or injury. Its focus is comfort, symptom and pain management, and palliation rather than cure. Hospice may be provided in the home or in hospice, hospital, nursing-home, or other long-term-care settings. Palliative care addresses pain, symptoms, and emotional distress associated with serious illness or its treatment and may accompany curative treatment at any age or stage of illness; it is distinct from hospice.

Service and Care-Level Definitions

Routine Home Care

DefinitionRoutine home care is the basic level of hospice care provided to support a patient with a terminal illness.

Typical settingIt may be provided in a private residence, hospital residential care facility, adult care home, or a contracted nursing facility.

Typical intensityIt typically requires fewer than eight hours of primarily nursing care per day, based on the patient's individual needs.

Continuous Home Care

DefinitionContinuous home care is provided in the patient's home during a medical crisis that might otherwise require inpatient admission.

ExamplesExamples of crises include dyspnea, delirium, or pain.

Policy Summary

PayerHealth-New-England

PolicyHospice and Palliative Care- Medical Policy

Policy CodePolicy UM1047POL

Change TypeMinor criteria changes

Effective DateDecember 1, 2026

Next Review DateNot specified

Key ActionFor services subject to prior authorization, submit clinical evidence demonstrating that the patient meets the applicable criteria.

SourceLink

On This Page

More than 50% of the continuous-care hours are nursing care provided by an R.N. or L.P.N.>50%

The plan of care is established with individualized member goals and periodically reviewed by the attending physician and interdisciplinary team.

The care provided is consistent with the plan of care.

Below the minimumWhen fewer than 8 hours of nursing and home health aide care are required in a 24-hour period, the care is covered as routine care.

Inpatient Respite Duration

Per-benefit-period limitInpatient respite care is short-term care of five days or less per benefit period.

Per-episode limitUp to five consecutive days of inpatient respite care may be approved per episode.

Care settingRespite care may be provided in a hospice facility, hospital, or nursing home.

Hospice Prognosis

Hospice prognosisThe physician or attending practitioner must certify a life expectancy of 6 months or less when hospice care is requested.

ApplicabilityThe 6-month prognosis applies to routine home hospice care and facility-based hospice care.

Certification limitationA nurse practitioner cannot certify or recertify terminal illness or provide a prognosis of 6 months or less.

This policy does not apply to the Medicare line of business. Medicare Advantage hospice is paid by Medicare fee-for-service under Medicare hospice benefit provisions; refer to HNE's Hospice Services Payment Policy.

HNE Hospice Services Payment Policy: https://healthnewengland.org/Portals/_default/Shared%20Documents/providers/Hospice.pdf

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed home health and hospice services identified as requiring PA in the coding guidance.

G0151 — Qualified physical therapist services: PA required
G0152 — Qualified occupational therapist services: PA required
G0153 — Qualified speech-language pathologist services: PA required
G0155 — Clinical social worker services: PA required
G0156 — Home health/hospice aide services: PA required
G0157 — Qualified physical therapist assistant services: PA required
G0158 — Qualified occupational therapist assistant services: PA required
G0299 — Direct skilled RN services: PA required

Unsupported block type: documentation

Documentation Required

Routine Home Hospice Documentation

For routine or ongoing home hospice care, document the required determination and certification, terminal prognosis, eligibility, election, plan of care, medical necessity, caregiver support, and agency availability.

Primary care physician or attending practitioner determines care is reasonable and medically necessary and certifies life expectancy of 6 months or less.
Member is functionally homebound and has elected or continues to elect hospice care.
Services manage and palliate the terminal illness and related conditions.
A willing and capable caregiver is available in the member's home.
Certified/accredited hospice agency provides care availability 24 hours per day, 7 days per week.

Documentation Required

Plan of Care and Review

Maintain a plan of care established and periodically reviewed by the attending physician, hospice medical director, and hospice interdisciplinary care group. The plan must support individualized, medically necessary management and palliation of the terminal illness and related conditions.

Document physician, hospice medical director, and interdisciplinary-team participation.
Record periodic reviews and continued alignment of services with the plan of care.

Documentation Required

Continuous Home Care Documentation

For continuous home hospice care, document that routine hospice criteria are met and that the member is in a crisis requiring continuous, predominantly nursing care to manage acute symptoms or achieve palliation and remain at home.

Record the crisis period, acute medical symptoms, and need for continuous care.
At least 8 hours of nursing and home health aide care are required in the 24-hour period from midnight to midnight; hours need not be continuous.
More than 50% of continuous hours must be provided by an RN or LPN.

Documentation Required

Facility-Based Care Documentation

For facility-based hospice or palliative care, document illness severity and the need for facility-based services, including prognosis when hospice care is requested and the inability to feasibly provide required symptom management elsewhere.

Physician and/or interdisciplinary team determines care is reasonable and medically necessary; hospice certification requires life expectancy of 6 months or less.
Document pain control or symptom management needs that cannot feasibly be provided in another setting.
Maintain an individualized plan of care with member goals, periodic review, and consistency between planned and delivered care.

Documentation Required

Respite Documentation

For inpatient respite care, document that the member meets home-based hospice criteria and that the caregiver requires relief from caregiving duties. Respite is short-term inpatient care, not residential or custodial care.

Document the physician or interdisciplinary team's support for caregiver relief.
Respite is limited to no more than 5 consecutive days per episode; up to 5 days of inpatient respite may be approved.

Billing Rule

Medicaid Regulatory Documentation and Billing

Medicaid providers should follow the referenced Massachusetts hospice services regulations for regulatory documentation and billing because Medicaid hospice services do not require prior authorization.

Massachusetts hospice services regulations: https://www.mass.gov/doc/hospice-services-regulations/download
Follow the regulations applicable to hospice services and billing for Medicaid (BeHealthy) members.

Documentation Required

Clinical Evidence Submission

The treating physician or primary care provider must submit clinical evidence to Health New England showing that the patient meets the criteria for the requested treatment, testing, or procedure.

Submit records supporting the requested service and medical necessity.
Clinical evidence is required for proper review of requests for prior authorization.

Denial Risk

Routine Home Hospice Criteria Not Met

Routine home hospice care may be denied when the required physician or attending-practitioner determination, terminal prognosis, homebound status, hospice election, plan of care, caregiver support, agency certification, or medical-necessity criteria is absent or unsupported.

The physician or attending practitioner must certify life expectancy of 6 months or less.
Services must be reasonable and necessary for management and palliation of the terminal illness and related conditions.

Denial Risk

Continuous Home Care Criteria Not Met

Continuous home care may be denied when routine hospice criteria are not met, the member is not experiencing a qualifying crisis, continuous care is not needed to maintain the member at home, or acute symptoms do not require predominantly nursing care.

The crisis must involve acute medical symptoms requiring continuous care for management or palliation.
Continuous care must be necessary to maintain the member at home.

Denial Risk

Insufficient Continuous-Care Hours

When fewer than 8 qualifying hours of nursing and home health aide care are required in a 24-hour period, continuous-care classification is not supported; the care is covered as routine care instead.

The 24-hour period begins and ends at midnight.
Care hours do not need to be continuous, but more than 50% of continuous hours must be nursing care by an RN or LPN.

Denial Risk

Facility-Based Level of Care Not Supported

Facility-based hospice or palliative care may be denied when the documentation does not support the required illness severity, prognosis where applicable, individualized plan of care, or need for facility-based symptom management.

Pain control or symptom management must not be feasibly deliverable in another setting.
Care must be consistent with the established and periodically reviewed plan of care.

Denial Risk

Respite Criteria or Duration Not Met

Respite care may be denied when the member does not meet home hospice criteria, caregiver relief is not documented, or the requested duration exceeds the applicable limit.

Document caregiver need for relief from care duties.
Respite is short-term inpatient care and is limited to no more than 5 consecutive days per episode.

Denial Risk

Intermittent Palliative Care Criteria Not Met

Intermittent palliative care may be denied when it is not provided under a physician-established and periodically reviewed plan of care, is not medically necessary and reasonable, or is not integral to treatment of the member's condition and associated symptoms.

Document physician oversight and periodic plan-of-care review.
Services must be consistent with accepted standards of clinical practice and the member's condition.

Note

Medicare Excluded from This Policy

Medicare is excluded from this policy. Medicare Advantage hospice follows Medicare fee-for-service hospice benefit provisions rather than the Commercial criteria in this policy.

Refer to HNE's Hospice Services Payment Policy for Medicare Advantage hospice payment guidance.

Denial Risk

Missing Clinical Evidence

Requests may not be properly reviewed for prior authorization without clinical evidence showing that the patient meets the applicable treatment or service criteria.

The treating physician or primary care provider must submit the supporting evidence.
Include sufficient medical records to establish medical necessity for the requested service.

Denial Risk

Benefit-Plan Exclusion

A finding that a service is medically necessary does not guarantee coverage or payment. The member's benefit plan governs, and services may remain excluded even when medical necessity is supported.

If the policy conflicts with the member's benefits program, the benefits program governs.
Coverage may also be affected by applicable state, federal, or CMS requirements.

Billing Rule

Medicaid Regulatory Documentation and Billing

Medicaid providers should follow the applicable Massachusetts hospice services regulations for required regulatory documentation and billing. No prior authorization is required for Medicaid members under this policy.

Massachusetts hospice services regulations: https://www.mass.gov/doc/hospice-services-regulations/download

Note

Medicare Hospice Payment Policy Applies

Medicare Advantage hospice is outside this policy and is paid by Medicare fee-for-service under Medicare hospice benefit provisions.

Use HNE's Hospice Services Payment Policy for applicable Medicare hospice payment guidance.

Care intensityAt least eight hours of primarily nursing care is required; nursing care need not be continuous, and home health aide services may supplement it.

Inpatient Respite Care

DefinitionInpatient respite care is short-term inpatient care intended to relieve family members and other unpaid caregivers caring for a patient at home.

DurationRespite care is five days or less per benefit period and may be approved for up to five consecutive days per episode.

Permitted settingsIt may occur in a hospice facility, hospital, or nursing home.

General Inpatient Care

DefinitionGeneral inpatient hospice care is provided to manage symptoms or perform pain-control procedures that cannot be performed in other settings.

Additional usesIt may be required for medication adjustment, observation, stabilizing treatment, or psychosocial monitoring.

Permitted settingsCare may be provided in a hospice inpatient facility, hospital facility, or nursing facility under arrangement with a hospice agency.

Nursing Care

Qualified personnelNursing care requires the skills of a registered nurse or licensed practical nurse under the supervision of a registered nurse.

Medical necessityThe services must be reasonable and necessary for treatment of the patient's illness or injury.

Additional providerNursing care may also include services provided by a nurse practitioner who is not the patient's attending physician.

Medical Social Services

ProviderMedical social services are provided by a social worker.

Required directionThe social worker must work under the direction of the physician.

Service roleThe services are part of hospice support provided under physician direction.

Physician Services

Hospice providerPhysician services may be provided by the hospice medical director.

Interdisciplinary teamServices may also be provided by a physician member of the interdisciplinary team.

Professional qualificationThe physician must be a Doctor of Medicine or osteopathy.

Attending Physician Services

Eligible professionalThe attending physician may be a Doctor of Medicine, doctor of osteopathy, or nurse practitioner.

Patient selectionThe patient identifies the attending physician at the time hospice care is elected.

RoleThe attending physician has the most significant role in determining and delivering the patient's medical care.

Counseling Services

Dietary counselingCounseling services may include dietary counseling.

Bereavement counselingCounseling services may include bereavement counseling.

Service scopeCounseling services are available as part of hospice support when included in the patient's care.

Medical Appliances and Supplies

Included itemsMedical appliances and supplies, drugs, and biologicals may be provided by the hospice team.

Primary purposeThese items are used primarily for relief of pain and control of symptoms related to the patient's terminal illness.

Relationship to careThe items support symptom control associated with the terminal illness.

Home Health Aide Services

PersonnelTrained home health aides provide these services under the supervision of a registered nurse.

Personal careAides may provide personal care services.

Household supportAides may perform household services to ensure a safe and sanitary environment in the home.