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    v1.0.31
    OpenPayerPolicy UpdatesHome Health & HospiceNew York DOH Hospice Policy Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentNew York State Department of HealthPolicy N/A

    Hospice Program Policy Guidelines

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    This manual governs eligibility, covered and disallowed services, plan-of-care requirements, and managed-care treatment for Medicaid beneficiaries who elect hospice. It applies to hospice providers and Medicaid recipients receiving hospice services across fee-for-service, Mainstream Managed Care, HIV Special Needs Plans, HARP, and applicable Managed Long Term Care arrangements.

    Policy Summary
    PayerNew York State Department of Health
    PolicyHospice Program Policy Guidelines
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage change
    Effective DateJanuary 2024
    Next Review DateN/A
    Key ActionBefore hospice coverage, obtain terminal-illness certification from the individual's physician and hospice medical director or designee, and document the individual's voluntary hospice election.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    <12 monthsHospice eligibility life expectancy
    4 rolesMinimum interdisciplinary team roles
    3 servicesServices prohibited with hospice
    5 categoriesMedicaid hospice payment categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Hospice Coverage Criteria

    Hospice Eligibility

    Hospice coverage is available when all eligibility requirements are met.

    Hospice eligibility

    • Terminal illness certification

      • The individual has a terminal illness with a life expectancy of fewer than twelve months per benefit period.Life expectancy <12 months per benefit period
      • The individual's physician certifies the terminal illness.
      • The hospice medical director or designee certifies the terminal illness.
    • The individual voluntarily elects hospice care.

      The election precludes use of other Medicare and/or Medicaid services for the terminal illness and related conditions; the individual may later rescind and reapply.

    Personal Care and Consumer Directed Services

    PCS and CDPAS may be authorized only when all applicable conditions are met.

    PCS/CDPAS eligibility

    • Services unrelated to terminal illness

      • The Personal Care Services or Consumer Directed Personal Assistance Services are necessary.
      • The services are included in a plan of care unrelated to the terminal illness.

    • Services predating terminal illness

      • The Personal Care Services or Consumer Directed Personal Assistance Services preceded the terminal illness.
      • The individual meets the Personal Care Services eligibility criteria.

    Covered Hospice Services

    Covered hospice services must be necessary for the patient's needs and provided under a written plan of care.

    Covered hospice services

    • Services are necessary to meet the patient's needs related to the terminal illness.Related to terminal illness and associated conditions
    • Services are provided according to a written plan of care.
    • Care is focused on easing symptoms rather than curing the disease.

    Plan of Care

    The plan of care must satisfy all stated operational requirements.

    Plan of care requirements

    • The individualized plan of care is established by the interdisciplinary group and overseen by a registered nurse coordinator.
    • The plan includes all services necessary for palliation and management of the terminal illness and related conditions.
    • The comprehensive assessment identifies needs that are not related to the terminal illness and related conditions, documents that the hospice is aware of those needs, and identifies who is addressing them.
    • The plan identifies needed durable medical equipment and the services to be provided for the terminal illness and related conditions.
    • The plan includes all diagnoses related to the terminal illness.

    Managed Care Treatment

    Managed-care coverage depends on the member's enrollment arrangement.

    Enrollment arrangement

    • Mainstream Managed Care

      • A person enrolled in Mainstream Managed Care, including an HIV Special Needs Plan or Health and Recovery Plan (HARP), may remain enrolled after electing hospice.Hospice is included in the managed-care benefit package

    • Medicaid fee-for-service

      • A person enrolled in Medicaid fee-for-service who elects hospice remains in Medicaid fee-for-service for the duration of approved hospice services and is not eligible to enroll in managed care or Managed Long Term Care.Fee-for-service per diem reimbursement

    • Managed Long Term Care

    The following Medicaid services are not allowed in combination with the hospice benefit: Private Duty Nursing, Certified Home Health Agency Services, and Adult Day Health Care services. Any overpayment resulting from duplicated services may be recouped from the hospice provider.

    PACE enrollment is incompatible with hospice enrollment. Individuals enrolled in PACE are not eligible for hospice because PACE plans have an alternate end-of-life program. An individual who elects hospice must be disenrolled from PACE before enrolling in hospice.

    Coding and Program Identifiers

    Recipient Restriction/Exception Codemixed
    C2-HOSPICE-MMMedicaid recipient restriction/exception (RR/E) code for a recipient who has elected hospice
    Required Hospice Notification Formmixed
    DOH-5778Entity/Facility Notification of Hospice NonCovered Items, Services, and Drugs
    Hospice Life Expectancy
    Required prognosisFewer than 12 months per benefit period

    Provider Requirements and Risk Points

    Documentation Required

    Certification and Hospice Election Required

    Before hospice eligibility is established, the individual's physician and the hospice medical director or designee must certify a terminal illness with a life expectancy of fewer than twelve months per benefit period. The individual must also voluntarily elect hospice care, which precludes use of other Medicare and/or Medicaid services for the terminal illness and related conditions.

    • The individual may rescind the election and reapply for hospice benefits later.
    Documentation Required

    Notify Other Providers of Noncovered Items and Services

    Hospice providers must maintain ongoing information sharing with other non-hospice providers furnishing services unrelated to the terminal illness and related conditions. Notify those providers of the noncovered diagnoses, services, and drugs and coordinate responsibility for unrelated needs.

    • Identify diagnoses and services related and unrelated to the terminal illness.
    • Ensure other providers, facilities, local departments of social services, and Medicaid Managed Care Organizations receive the applicable notification.

    Hospice Program Overview

    Hospice is a coordinated home and inpatient program that treats the terminally ill individual and family as a unit through an interdisciplinary team. Care is palliative and supportive, addressing physical, psychological, spiritual, social, and economic stresses during the final stages of illness, dying, and bereavement, with services focused on easing symptoms rather than curing the disease.

    Key Terms

    Hospice Program
    DefinitionA coordinated program of home and inpatient care that treats a terminally ill individual and family as a unit.
    Care modelEmploys an interdisciplinary team.
    AdministrationOperates under the direction of an autonomous hospice administration.
    Terminal Illness
    DefinitionA medical prognosis caused by injury, disease, or illness from which there is no reasonable medical probability of recovery.
    Palliative Care
    Definition
    Policy Summary
    PayerNew York State Department of Health
    PolicyHospice Program Policy Guidelines
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage change
    Effective DateJanuary 2024
    Next Review DateN/A
    Key ActionBefore hospice coverage, obtain terminal-illness certification from the individual's physician and hospice medical director or designee, and document the individual's voluntary hospice election.
    SourceLink
    On This Page
    Hospice Coverage CriteriaCoding and Program IdentifiersProvider Requirements and Risk PointsHospice Program OverviewKey Terms
  1. The plan includes diagnoses directly related to services the patient receives from non-hospice health care providers.
  2. The hospice provides for ongoing information sharing with non-hospice health care providers furnishing services unrelated to the terminal illness and related conditions.
    3. A person enrolled in Partial Capitation, Medicaid Advantage Plus (MAP), or Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) may remain enrolled after electing hospice.

  3. PACE

    • A person enrolled in the Program of All-Inclusive Care for the Elderly (PACE) must disenroll from PACE before enrolling in hospice.

      Individuals enrolled in PACE are not eligible for hospice while enrolled in PACE because PACE plans have an alternate end-of-life program.

    4. Billing Rule

    Record the C2-HOSPICE-MM Restriction Code

    Ensure that the hospice recipient restriction/exception (RR/E) code C2-HOSPICE-MM is placed on the Medicaid recipient's eMedNY record after hospice election.

    • For dual-eligible recipients, the code is added systematically from the Medicare hospice election data and returned on the ePACES eligibility response.
    • For non-dual Medicaid recipients, submit the completed Hospice Care RR/E Code Update Form to hospicebilling@health.ny.gov for manual entry.
    Documentation Required

    Complete and Distribute DOH-5778

    Complete DOH-5778, Entity/Facility Notification of Hospice NonCovered Items, Services, and Drugs, and share it with the patient's other medical providers and facilities, including local departments of social services and Medicaid Managed Care Organizations.

    • In Section II, provide diagnosis information using appropriate diagnostic terminology rather than a diagnosis code.
    • Identify diagnoses as related in Section II.A. or unrelated in Section II.B. to the terminal illness and associated conditions.
    Documentation Required

    Maintain the Individualized Plan of Care

    Develop an individualized plan of care (POC) established by an interdisciplinary group (IDG) and overseen by a registered nurse (RN) coordinator. The POC must include all services necessary to palliate and manage the terminal illness and related conditions.

    • Document unrelated needs identified in the comprehensive assessment, including who is addressing them.
    • Identify needed durable medical equipment and services for the terminal illness and related conditions.
    • Include all diagnoses related to the terminal illness, including diagnoses directly related to services delivered by non-hospice providers.
    Denial Risk

    Missing Certification or Hospice Election

    Without both required terminal-illness certification and the individual's voluntary hospice election, hospice eligibility is not established and payment may be denied.

    • Certification must be by the individual's physician and the hospice medical director or designee.
    • The prognosis must be fewer than twelve months per benefit period.
    Denial Risk

    Duplicate or Incompatible Services

    Do not provide or bill Medicaid services that are prohibited in combination with the hospice benefit. Overpayments resulting from duplicate services may be recouped from the hospice provider.

    • Private Duty Nursing
    • Certified Home Health Agency Services
    • Adult Day Health Care service
    Denial Risk

    Adequate Plan of Care and Relatedness Determination

    The plan of care must be individualized and must distinguish services and diagnoses related to the terminal illness from unrelated needs. Inadequate documentation of diagnosis relatedness or failure to provide for unrelated needs can create coverage and payment risk.

    • The hospice must document awareness of needs unrelated to the terminal illness and identify who is addressing them.
    • The POC must include diagnoses related to the terminal illness and diagnoses directly related to services received from non-hospice providers.
    • Maintain ongoing information sharing with non-hospice providers furnishing unrelated services.
    Denial Risk

    PACE Enrollment Conflict

    Individuals enrolled in PACE are not eligible for hospice because PACE has an alternate end-of-life program. An individual who elects hospice must be disenrolled from PACE before hospice enrollment.

    • This restriction applies specifically to PACE enrollment; other listed MLTC arrangements may allow continued enrollment under their applicable rules.
    Active, interdisciplinary care for patients with advanced, life-limiting illness.
    FocusRelief of distressing physical and psychosocial symptoms and meeting spiritual needs.
    GoalAchievement of the best quality of life for patients and families.
    Palliation
    DefinitionEasing the severity of pain or disease without removing the cause.