CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hospice Services — Coverage Criteria

Defines Neighborhood Health Plan of Rhode Island coverage, limitations, and billing codes for hospice services and respite care across member benefit packages, and who is eligible to receive hospice under the plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHospice Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for the all‑inclusive hospice service package and ensure a Neighborhood physician certifies the patient is terminally ill and appropriate for hospice care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysinitial authorized hospice period in nursing home for RHP and RHE members

5 daysmaximum respite inpatient admission for specified member groups

Q5001-Q5007, Q5009, T2042-T2046, S9125-S9126, T2044listed HCPCS/HCPCS-like codes referenced for hospice/respite

2010–2014version history range

Coverage Criteria for Hospice Services

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHospice Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain authorization for the all‑inclusive hospice service package and ensure a Neighborhood physician certifies the patient is terminally ill and appropriate for hospice care.

SourceLink

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Covered hospice services

Covered when ALL of the following are met

Physician certification: Services provided under the direction of a Neighborhood physician who certifies the patient is in the terminal stages of illness and appropriate for hospice care.

Required for hospice coverage per policy

Scope of hospice services: Hospice includes physician, nurse practitioner, skilled nursing, rehabilitative, social work, chaplain and certified nursing assistant services; also includes durable medical equipment and medications related to the terminal illness, bereavement care, and respite care.

Alignment with CMS guidance: Hospice services are covered per CMS guidelines and the hospice benefit coverage aligns with CMS guidance.

Service settings: Hospice services are covered when provided in the home, individual hospice facility, skilled nursing facility (SNF), or inpatient hospital settings; respite services are covered as part of the hospice benefit.

Authorization and package: Hospice is an all‑inclusive service package that requires authorization; separate authorizations are not required for services included in the hospice package.

Benefit‑package specific limits: Respite care for RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners and ACA Adult Expansion must occur in an inpatient setting and cannot exceed a 5 day admission; Neighborhood will authorize the first 30 days of hospice care for RHP and RHE members when delivered in a nursing home, after which Medical Assistance fee‑for‑service will reimburse hospice care and room and board per policy; room and board payment rules for Rhody Health Options Phase One are addressed separately.5 days; 30 days

See benefit details for RHO Phase One long‑term services and supports.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required for Hospice Package

Hospice services are an all‑inclusive service package and require prior authorization from Neighborhood Health Plan of Rhode Island. Authorization covers the full hospice package; separate authorizations are not required for services included in the hospice benefit (for example: physician, nurse practitioner, skilled nursing, home health aide, social work, chaplain, certified nursing assistant, inpatient hospice facility, SNF, hospital, DME and medications related to the terminal illness, bereavement, and respite care).

Authorization required for the full hospice package; do not submit separate prior authorizations for included services
Authorization applies to hospice-covered services related to the terminal illness
Follow CMS guidelines and plan-specific authorization processes

Note

30‑Day Nursing Home Authorization and Payment Shift

Neighborhood will authorize the first thirty (30) days of hospice care for Rhody Health Partners (RHP) and RHE members when hospice care is delivered in a nursing home. Beginning on day 31, Medical Assistance fee‑for‑service will reimburse hospice care and room and board as applicable. For Rhody Health Options Phase One members in a nursing home receiving hospice, Neighborhood will pay the room and board; Medicare will pay for the skilled hospice services associated with the hospice stay.

First 30 days authorized by Neighborhood for RHP and RHE in nursing home settings
Day 31 onward: Medical Assistance FFS reimburses hospice care and room & board where applicable
RHO Phase One: Neighborhood pays room & board; Medicare covers skilled hospice services

Documentation Required

Physician Certification Required

Hospice services must be provided under the direction of a Neighborhood physician who certifies that the patient is terminal and appropriate for hospice care. Physician certification of terminal status is required for hospice coverage.

Physician certification of terminal prognosis required
Care must be provided under the direction of a Neighborhood physician

Denial Risk

Non‑Terminal Services Excluded from Hospice Benefit

Services that are unrelated to the terminal illness are excluded from the hospice benefit. Such non‑terminal services should not be billed under hospice and may be denied; they may instead be covered under the member's regular benefit package when appropriate.

Exclude and do not bill non‑terminal treatments/services under hospice
Non‑terminal services may be billed and adjudicated under the member's standard benefit package if covered

Definitions

Hospice — definition and included disciplines

DefinitionHospice: end-of-life care provided under the direction of a Neighborhood physician who certifies the patient is in the terminal stages of illness and appropriate for hospice care.

Included disciplines/servicesPhysician; nurse practitioner; skilled nursing; rehabilitative services; social worker; chaplain; certified nursing assistant (CNA).

Included settingsHome setting; inpatient hospice facility; skilled nursing facility (SNF); hospital.

Additional benefit componentsDurable medical equipment (DME) and medications related to the terminal illness or care; bereavement care; respite care.

Palliative care — definition

DefinitionPalliative care: continued, active, preventive medical treatment with skilled nursing services and home health aide visits for patients with acute or chronic progressive illnesses.

Relation to hospice benefitPalliative care is not part of the hospice benefit.

Typical servicesSkilled nursing services and home health aide visits provided as part of ongoing medical treatment.

Background

Hospice is end-of-life care that covers a multidisciplinary package of services provided when a member is certified as terminally ill. Covered hospice services include medical direction and oversight, nursing and skilled nursing services, rehabilitative therapies, social work, chaplaincy, certified nursing assistant support, durable medical equipment and medications related to the terminal illness, bereavement services, and respite care. These services are delivered in the home, inpatient hospice facility, skilled nursing facility, or hospital settings in accordance with CMS guidelines.

Hospice is provided as an all-inclusive service package requiring authorization; individual services included in that package do not require separate prior authorizations. Respite care for certain member groups is limited to a maximum of 5 days per inpatient admission, and specific member groups (Rhody Health Partners and ACA Adult Expansion) have program-specific rules for room and board coverage and an initial 30-day authorized nursing home hospice period after which payment responsibilities may shift.

Q5003
Q5004
Q5005
Q5006
Q5007
Q5009
T2044
T2045
T2046

OpenPayer

Hospice Services — Coverage Criteria

Coverage Criteria for Hospice Services

Coding and Billing Codes

Provider Actions and Authorization Requirements

Definitions

Background

Revision History

Q5001
Q5002
Q5009
S9125
S9126
T2042
T2043