CurrentKansas Department of Health and EnvironmentPolicy N/A

Hospice services for Kansas Medicaid beneficiaries — coverage criteria

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Governs Kansas Medicaid coverage, eligibility, payment, utilization trends, and program oversight for hospice services provided to terminally ill beneficiaries (home, hospital, nursing facility, or skilled nursing facility). Affects hospice providers serving Kansas Medicaid beneficiaries and KHPA fiscal operations.

Policy Summary

PayerKansas Department of Health and Environment

PolicyHospice services for Kansas Medicaid beneficiaries — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2008

Last ReviewDec 1, 2008

Next Review DateN/A

Key ActionSubmit hospice election and initial drug requests to the MMIS customer website within 10 days and obtain required certifications to ensure timely coverage and avoid increased scrutiny.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentKansas Department of Health and EnvironmentPolicy N/A

Hospice services for Kansas Medicaid beneficiaries — coverage criteria

Customize your policy alerts

Sign up for all Kansas Department of Health and Environment policy alerts

Know when Kansas Department of Health and Environment releases new policies or updates existing guidance.

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Policy Summary

PayerKansas Department of Health and Environment

PolicyHospice services for Kansas Medicaid beneficiaries — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2008

Last ReviewDec 1, 2008

Next Review DateN/A

Key ActionSubmit hospice election and initial drug requests to the MMIS customer website within 10 days and obtain required certifications to ensure timely coverage and avoid increased scrutiny.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3,423Beneficiaries (2008)

$25.2MClaims paid (2008)

139%Expenditure growth FY03–FY07

68→95→76Providers (trend)

~72%SNF share (3-yr avg)

Coverage Criteria and Policy Notes

Basic hospice eligibility

Covered when ALL of the following are met

Eligibility certifications: Certified terminally ill by the hospice medical director or physician member of the hospice interdisciplinary team AND certified terminally ill by the beneficiary's attending physicianlife expectancy <= 6 months

Both certifications required per Kansas Medicaid; aligns with Medicare COPs

Beneficiary election: Beneficiary has filed an election statement completed by the attending physician and signed by the beneficiary indicating that the condition is terminal and life expectancy is six months or lesssigned election on file and submitted to KHPA fiscal agent

Election submitted to KHPA's fiscal agent changes Medicaid payment status to hospice

Payment allocation for related and unrelated services

Coverage notes for related vs unrelated services

Related services: Services related to the terminal diagnosis/illness (including bundled ancillary services) are paid to the hospice and are included in the hospice payment codesrelated to terminal diagnosis

Includes routine home care, continuous care, respite, medications related to terminal illness, DME and ancillary services; these items are part of the hospice bundle and are not visible in MMIS as separate pharmacy or ancillary claims

Unrelated services: Services not related to the terminal illness that meet Medicaid coverage and program guidelines are paid separately to non-hospice providers through MMISnot related to terminal diagnosis

Prior authorization is required for all other Medicaid services during hospice enrollment to ensure payment for medically appropriate, non-duplicated services

Recommended coverage controls and reviews

Recommendations to clarify and/or implement coverage controls and reviews

Policy redevelopment and monitoring: Redevelop the Kansas Medicaid Hospice Provider Manual to clarify covered services, reimbursement rules, medication monitoring for payment, prior and retrospective authorization review guidelines, admission and length-of-stay reviews, and HCBS concurrent stay reviews

Consider incorporating revised 42 CFR 418 (Medicare COPs) and specified program clarifications

Medication payment responsibility categories: Assign medications into categories with assigned payment responsibility: (1) medications never appropriate for hospice (e.g., unapproved therapies) to be denied or patient/family paid; (2) medications not covered by hospice or Kansas Medicaid (e.g., vitamins, health additives) patient/family paid; (3) medications the responsibility of hospice (analgesics, antianxiety, oxygen, non-curative meds related to terminal disease); (4) medications the responsibility of Kansas Medicaid (medically necessary meds not related to terminal diagnosis, e.g., insulin)

Also allow case-specific determinations for borderline items (skin/wound products, antibiotics, antihypertensives)

Admission and length-of-stay (LOS) reviews: Place some restrictions on hospice admission and use SURS or PA units to review admissions; examine LOS by diagnosis and medication use and review individual stays after designated time frames (e.g., 90 days or 6 months)

When a beneficiary elects hospice care, Medicaid benefits that are considered preventive, curative, or restorative are waived for the duration of the hospice enrollment. Hospice provides comfort care, palliation of symptoms, and support during the dying process and therefore coordinates benefits and the individualized plan of care. While the hospice is responsible for services related to the terminal diagnosis, unrelated services that remain covered and meet program guidelines may be paid separately to non-hospice providers through the MMIS when prior authorization is obtained.

Providers must request prior authorization for all non-hospice Medicaid services during hospice enrollment to ensure Medicaid reimburses only for medically appropriate, non-duplicated services. Examples of hospice-bundled services include routine home care, continuous care, respite care, certain medications related to the terminal diagnosis, DME, and ancillary services; these are paid to the hospice and not billed separately through MMIS.

The policy recommends establishing medication categories and assigning payment responsibility. One category is medications never appropriate for hospice, which includes unapproved drugs or therapies such as Laetrile and chelation, as well as commonly used preventive or disease-modifying medications that are not appropriate for terminal patients (for example, some hormonal therapies, statins, and osteoporosis treatments). These items are identified as outside hospice responsibility and would be excluded or assigned to patient/family payment or denial.

Kansas identified a risk that MMIS paid pharmacy claims for curative medications when retroactive Medicaid eligibility was applied after the date of hospice election. To reduce inappropriate curative drug payments, the state implemented a policy requiring hospices to submit the original election and initial drug requests into the MMIS customer website within 10 days. Requests not entered within this timeframe undergo increased scrutiny to determine the appropriate effective date for hospice services and may limit unauthorized curative drug reimbursements.

The recommendations specify that vitamins, health additives, and patient personal choice items considered not medically necessary by treating providers (for example, bee pollen or similar supplements) should be classified outside hospice or Medicaid coverage and be the financial responsibility of the patient or family.

Procedure Codes, Prognosis, and Related Coding Notes

Hospice procedure codes referencedHCPCS

T2042	Routine Home Care
T2043	Continuous Home Care
T2044	Respite Care
T2045	General Inpatient Care
T2046	Room and Board, Nursing Facility

Prognosis life expectancy — 6 months or less

Prognosis life expectancySix months or less

Certification requiredCertified terminally ill by hospice medical director or physician member of hospice interdisciplinary team and by the beneficiary's attending physician

Evidence of electionBeneficiary must file an election statement completed by the attending physician and signed by the beneficiary indicating life expectancy of six months or less

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required; timely MMIS entry of election and initial drug requests

Prior authorization is required for all other Medicaid services while a beneficiary is enrolled in hospice. Hospice election and the initial drug requests must be entered into the MMIS customer website within 10 days; requests not entered within 10 days undergo increased scrutiny to determine an appropriate effective date for hospice services and drug coverage.

Enter the election statement and initial drug requests into MMIS within 10 days of election to avoid increased scrutiny.
Obtain prior authorization for any non-hospice Medicaid services during hospice enrollment before billing.

Prior Authorization

Develop PA and retrospective authorization & admission review processes

Policy recommends developing prior and retrospective authorization review guidelines and using SURS or PA units to place some restrictions on hospice admissions and to review length of stay and medication use.

Expect potential future requirements for PA or SURS-based admission reviews and retrospective authorization processes.

Background and Program Overview

Hospice is a physician-directed, nurse-coordinated interdisciplinary program that provides palliative, non-curative care to terminally ill patients with an expected life expectancy of six months or less. Care focuses on symptom management and family support and may be provided in the home, hospital, nursing home, or skilled nursing facility. Certification by the hospice medical director (or physician member of the interdisciplinary team) and the patient's attending physician, together with a signed election statement, are required to establish hospice eligibility.

Terms and Service-Level Definitions

Hospice — Definition of hospice provider meeting Medicare Conditions of Participation

Definition of hospice providerA public agency or private organization primarily engaged in providing care to terminally ill individuals that meets Medicare Conditions of Participation (42 CFR 418)

Program modelPhysician-directed, nurse-coordinated interdisciplinary team available 24 hours a day, seven days a week

Service settingsServices provided in home, hospital, nursing home or skilled nursing facility

Election statement — Statement completed by the attending physician and signed by the beneficiary indicating terminal condition and life expectancy

Election statement requirementCompleted by the attending physician and signed by the beneficiary indicating the condition is terminal and life expectancy is six months or less; submitted to KHPA's fiscal agent to change Medicaid payment status to hospice

Policy Summary

PayerKansas Department of Health and Environment

PolicyHospice services for Kansas Medicaid beneficiaries — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2008

Last ReviewDec 1, 2008

Next Review DateN/A

Key ActionSubmit hospice election and initial drug requests to the MMIS customer website within 10 days and obtain required certifications to ensure timely coverage and avoid increased scrutiny.

SourceLink

On This Page

Reviews intended to identify patterns of inappropriate stays or medication administration

Retroactive eligibility handling: Implement processes to identify hospice beneficiaries earlier and require hospices to furnish admission data (medications, diagnosis, LOS, expenditures) to reduce inappropriate payments; use program manager review to approve, partially approve, or deny retroactive eligibility claims

Addresses risk that Medicaid may have paid for services or medications that should have been hospice-responsible when MMIS was not flagged

Prepare to support LOS and medication-use reviews by maintaining accessible admission and treatment records.

Step Therapy

Step therapy not specified

No step therapy or step-edit requirements are specified in this document segment.

Billing Rule

Categorize medications and assign payment responsibility

Recommend monitoring and categorizing medications with assignment of payment responsibility among hospice, Kansas Medicaid, patient/family, or case-specific determinations as described by the Hospice Task Force.

Medications never appropriate for hospice (e.g., Laetrile, chelation) — patient/family or denied.
Medications not covered by hospice or Kansas Medicaid (e.g., vitamins, health additives) — patient/family paid.
Medications the responsibility of hospice (e.g., analgesics, antianxiety medications, oxygen) — hospice pays.
Medications the responsibility of Kansas Medicaid (medically necessary but unrelated to terminal diagnosis, e.g., insulin) — Medicaid pays.
Case-specific responsibilities determined individually (e.g., skin/wound products, antibiotics).

Documentation Required

Document certifications and signed election statement for hospice eligibility

Hospice eligibility requires certification as terminally ill by the hospice medical director or physician member of the interdisciplinary team and by the beneficiary's attending physician, plus a signed election statement completed by the attending physician and signed by the beneficiary indicating life expectancy of six months or less; the notice is submitted to KHPA's fiscal agent to switch Medicaid payment status to hospice.

Maintain both hospice interdisciplinary-team certification and attending physician certification in the medical record.
Ensure a completed, signed election statement is submitted to KHPA's fiscal agent to change payment status.

Documentation Required

Provide medication, diagnosis, LOS, and expenditure data at admission/election

Recommend that hospices furnish medication lists, diagnoses, length-of-stay, and expenditure information as part of the admission/election process to aid early identification and review of retroactive eligibility and claims.

Include medication lists and recent diagnoses with the admission/election submission.
Provide anticipated or current length-of-stay and known expenditures to facilitate retrospective review.

Prior Authorization

Obtain prior authorization for non-hospice Medicaid services during hospice enrollment

Prior authorization is required for all other Medicaid services while a beneficiary is enrolled in hospice to ensure Medicaid reimburses only medically appropriate, non-duplicated services.

Obtain PA for any non-hospice services before billing Medicaid during hospice enrollment.

Denial Risk

Submit election and initial drug requests into MMIS within 10 days

Failure to submit the original election and the initial drug requests into MMIS within 10 days triggers increased scrutiny and may affect the effective date for hospice services and drug coverage.

Submit election and initial drug requests into the MMIS customer website within 10 days to avoid retrospective adjustments.

Denial Risk

Retroactive eligibility reviews may result in full approval, partial approval, or denial

Retroactive eligibility reviews can result in three outcomes: approve all services, approve a portion and deny the remainder for not meeting program guidelines, or deny the entire claim; pharmacy claims will have been paid prior to these determinations, creating potential recovery or cost concerns.

Retrospective approvals may lead to payment of claims that later are found inappropriate for hospice responsibility.
Program manager review determines final retroactive eligibility outcome and potential denials.

Indicates beneficiary elects hospice services and accepts limitations on curative care

Documentation timingElection must be on file to effect payment status change in MMIS

Routine Home Care (T2042) — Includes routine nursing care, social services, DME, supplies, drugs, home health personnel, personal care attendants

CodeT2042 — Routine Home Care

IncludesRoutine nursing care, social services, durable medical equipment (DME), supplies, drugs, home health personnel, personal care attendants, and PT/OT/SLP when included in the treatment plan and prior authorized

SettingProvided as part of hospice's routine home care services and paid under hospice bundled payment

Continuous Home Care (T2043) — 24-hour/day nursing care during acute medical crisis in the home

CodeT2043 — Continuous Home Care

DefinitionLevel of care provided during periods of acute medical crisis requiring 24‑hour/day nursing care in the home

UsageProvided under extreme circumstances due to staffing and cost intensity

Respite Care (T2044) — Respite care in a licensed nursing facility or contracted acute care hospital; predominantly used in rural areas

CodeT2044 — Respite Care

DefinitionRespite care provided in a licensed nursing facility or an acute care hospital contracted with the hospice

Utilization notePredominantly used in rural areas; lower total reimbursement amounts compared with other hospice services

General Inpatient Care (T2045) — Hospital-level palliative care during acute medical crisis or for admissions not related to the terminal illness

CodeT2045 — General Inpatient Care

DefinitionHospital-level palliative care during periods of acute medical crisis or for admissions not related to the terminal illness

ExamplesAdmissions for acute symptom management or non‑terminal events (e.g., fall with broken leg)

Room and Board, Nursing Facility (T2046) — Hospice-payment for room and board in nursing facility; Kansas Medicaid reimburses hospice 95% of the room and board rate as determined by Dept on Aging

CodeT2046 — Room and Board, Nursing Facility

Payment ruleKansas Medicaid reimburses hospice 95% of the nursing facility room and board rate as determined by the Kansas Department on Aging

Billing flowHospice bills Medicaid for room and board and then pays the nursing facility at a contracted rate