Currentsierra health and lifePolicy N/A

Hospice services — coverage criteria and admission

Defines hospice eligibility, admission criteria, covered services, and referral process for Sierra Health and Life members receiving hospice care in Nevada.

Policy Summary

Payersierra health and life

PolicyHospice services — coverage criteria and admission

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInitiate referral by contacting a contracted Medicare/Medicaid certified hospice agency listed in the plan directory.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsprognosis threshold

All memberscoverage

24/7availability

Interdisciplinarycare model

Hospice Coverage Criteria

Admission Criteria

Covered when ALL of the following are met

Policy Summary

Payersierra health and life

PolicyHospice services — coverage criteria and admission

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInitiate referral by contacting a contracted Medicare/Medicaid certified hospice agency listed in the plan directory.

SourceLink

On This Page

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Physician determination: Attending physician and hospice medical director make a clinical determination that life expectancy is six months or less if the disease follows its usual course.<= 6 months

Supported by clinical judgment; see examples of conditions that may suggest eligibility.

Patient election: Patient has been informed of a terminal diagnosis with a prognosis of six months or less and has elected no additional curative treatment; care will be directed toward comfort measures.election documented

Referrals may originate from physician, patient, family, social workers, or clergy.

The list of diagnoses provided in this policy (for example: terminal cancer, end‑stage COPD, end‑stage cardiomyopathy, end‑stage renal failure where dialysis has been stopped, end‑stage CHF, ALS, end‑stage PVD, HIV/AIDS, end‑stage dementia, stroke, Parkinson’s disease) are illustrative examples that may suggest hospice eligibility. These examples are not exhaustive and do not replace professional judgment, nor do they supersede applicable CMS regulations or any relevant local coverage determinations (LCDs).

Referral and Admission Actions for Providers

Note

Referral to contracted hospice agency

Refer to a Medicare/Medicaid-certified hospice agency contracted with the plan. Initiate referrals by contacting a contracted hospice agency (see the plan's online directory). Hospice services are available 24 hours a day, 7 days a week.

Call the plan's contracted hospice agency listed in the Health Plan of Nevada online directory
Referrals may be initiated by physician, patient, family, friends, social workers, or clergy
Hospice agencies must be Medicare/Medicaid certified and contracted with the plan

Documentation Required

Admission documentation requirement

Admission requires documented patient notification and election. The record must show the patient has been informed by their physician of a terminal diagnosis with a prognosis of six months or less and has elected to forgo additional curative treatment so that care is directed toward comfort measures.

Documentation must state the patient was informed by the physician of a terminal diagnosis with prognosis ≤ six months
Documentation must state the patient has elected no additional curative treatment and chosen comfort-directed care

Documentation Required

Clinical determination and election

Clinical determination of eligibility must be made by the attending physician and the hospice medical director. Documentation must support that life expectancy is six months or less if the disease follows its usual course and that the patient has elected hospice care.

Attending physician and hospice medical director must determine life expectancy ≤ six months
Clinical notes should document the prognosis and the patient's election for hospice

Step Therapy

No step therapy specified

No step therapy or prior-step requirements apply for hospice admission. Admission decisions are based on clinical determination and the patient's election for comfort-directed care.

No step therapy specified
Admission depends on clinical prognosis and the patient's election for hospice (comfort-directed care)

Key Definitions

Hospice — definition and scope

Hospice definitionComprehensive, patient‑centered care focused on meeting the physical, emotional, and spiritual needs of individuals with life‑limiting or terminal conditions, provided by Medicare/Medicaid certified agencies under an interdisciplinary team

Care settingsMay be delivered in the home, custodial residences, or contracted inpatient facilities based on patient needs

Admission triggerPatient informed of terminal diagnosis with prognosis ≤ six months and elected no additional curative treatment

Admission criteria (definition)

Patient notificationPatient has been informed by their physician of a terminal diagnosis with a prognosis of six months or less

Election of carePatient has elected no additional curative treatment and care will be directed toward comfort measures

Referral sourcesReferrals may originate from physicians, patients, family, friends, social workers, or clergy

OpenPayer

Hospice services — coverage criteria and admission

Hospice Coverage Criteria

Prognosis and Coding Considerations

Referral and Admission Actions for Providers

Policy Background

Key Definitions