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    OpenPayerPolicy UpdatesHome Health & HospiceWest Virginia Medicaid Hospice Policy Update | Ope…
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    CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

    Comments and updates to Chapter 509 Hospice Services (Coverage Criteria)

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    Comments and resulting updates to West Virginia Medicaid Chapter 509 Hospice Services outlining provider participation, service requirements, benefit periods, enrollment/certification timelines, billing/reimbursement categories, and coordination with waiver and PCS programs; affects hospice providers serving WV Medicaid members.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyChapter 509 Hospice Services — comments and resulting updates (Coverage Criteria)
    Policy CodePolicy N/A
    Change TypeClarifications and minor wording changesone material addition to eligibility language
    Effective DateMay 1, 2020
    Last ReviewMay 1, 2020
    Next Review DateN/A
    Key ActionMaintain required physician certification within the state timeline and retain documentation of referrals, plan of care/IPP, and coordination with PCS/waiver case management.
    SourceLink
    POLICY UPDATE CHANGES

    Language was added to indicate hospice eligibility can include when curative medicine options 'are not desired' in addition to being exhausted.

    The term 'accreditation' was removed from provider participation requirements because accreditation is not required in West Virginia.

    Wording in hospice service requirements was clarified by adding 'services that' to resolve an incomplete sentence about services 'not considered core services'.

    Clarification added regarding coordination/interaction between hospice services and Home and Community Based Waiver (HCBS) and Personal Care Services (PCS), including that waiver services are primary when members receive other Medicaid services.

    Updated Billing & Reimbursement section to reference the five CMS hospice payment categories and added explanatory language and referral to prior BMS memorandum about payment methodology.

    Requirement for physician certification timeline (8-day rule) retained per WV State Plan; requests to remove or alter were not adopted.

    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.

    5CMS hospice payment categories referenced
    >=2Public comment dates reflected (July–Aug 2019)
    MultiplePolicy language clarifications implemented

    Coverage Criteria and Conditions

    Coverage conditions and notes

    Covered hospice services and conditions referenced or clarified in the updated Chapter 509:

    Hospice eligibility: Member is eligible for hospice when the possibilities of curative medicine have been exhausted OR curative options exist but are not desired by the patient; care focuses on palliation and comfort.

    Language added to reflect patient preference as a valid consideration.

    Certification timeline: Written physician certification must be obtained within the state-prescribed timeline (including applicable oral-certification exceptions); services furnished before timely certification may be ineligible for reimbursement.8-day rule referenced in comments

    Requirement retained per WV State Plan; oral-certification exception applies when written certification cannot be obtained within 2 calendar days.

    Enrollment and election periods: A member's election period governs hospice enrollment; once elected, re-election is unnecessary unless the member revokes or is discharged. Revocation and discharge rules follow federal regulations cited in policy (42 CFR §§418.24, 418.26, 418.28).

    Policy retained current federal/state provisions on election, revocation, and discharge.

    Billing categories: Reimbursement aligns with CMS hospice payment categories: Routine Home Care (RHC), RHC Service Intensity Add-on Payments (SIA), Continuous Home Care (CHC), Inpatient Respite Care (IRC), and General Inpatient Care (GIC/GIP).

    Policy references CMS payment categories and prior BMS memorandum regarding the hospice payment methodology.

    Coordination with waiver and PCS services: Waiver services (HCBS) and Personal Care Services (PCS) are primary when a member receives other Medicaid services; hospice must not duplicate waiver/PCS services and must coordinate care to avoid duplication.

    Providers must document referrals, the member's plan of care or IPP, and coordination with PCS/waiver case management; documentation of concurrent service need must be retained in both records.

    When a Medicaid member is receiving Home and Community Based Waiver services or Personal Care Services (PCS), those waiver/PCS programs are considered primary. Hospice providers must not duplicate services that are already furnished under a waiver or PCS benefit, and the same type of service may be provided by both programs only if not provided at the same time. Coordination and documentation of need must be maintained in the member's plan of care or Individual Program Plan (IPP), and referral documentation should be retained in both the coordination/case management agency and the hospice provider records.

    Written physician certification is required within the state-prescribed timeline; failure to obtain the required certification within that timeline may render hospice services furnished before certification ineligible for reimbursement. The policy retains the existing certification timeline per the West Virginia State Plan, including applicable oral-certification exceptions and the requirement to obtain written certification before submitting a claim for payment.

    Provider Responsibilities, Documentation, and Billing Alerts

    Prior Authorization

    Prior authorization for level‑of‑care changes

    Public comments requested clarification that a hospice change in level of care should not require prior authorization. The policy comments do not add an explicit prior authorization requirement; no change was made to impose prior authorization for level-of-care changes.

    Note

    Waiver services are primary; avoid duplicating PCS/HCBS services

    A commenter flagged the requirement that waiver services are primary when a member is receiving any other Medicaid service; hospice must not duplicate waiver/PCS services and should coordinate to avoid concurrent duplication.

    • Waiver services are considered primary if the member is receiving any other Medicaid service.
    • The same type of service may be provided by both programs but not at the same time (avoid duplication).

    Key Definitions

    Hospice eligibility language — key change
    Updated eligibility phraseMember is eligible for hospice when 'the possibilities of curative medicine have been exhausted or are not desired.'
    Reason for changeAdded to acknowledge that patients may decline available curative treatments because they are too burdensome or contrary to comfort-oriented goals.
    Source of changeIncorporated following multiple public comments received July–August 2019 requesting the phrase 'or are not desired.'
    Policy effectClarifies that hospice eligibility can be based on patient preference to forgo curative treatment as well as when curative options are exhausted.

    Background

    Hospice provides palliative care and supportive services to individuals with terminal illnesses when curative treatment options have been exhausted or are not desired, focusing on symptom management, comfort, and quality of life rather than curative goals.

    Effective coordination with Medicaid waiver programs and PCS is necessary to avoid duplication of services and to ensure continuity of care; documentation of referrals, the member's plan of care or IPP, and inter-provider communication should be maintained as part of hospice case management.

    Policy Summary
    PayerWest Virginia Bureau for Medical Services (Department of Human Services)
    PolicyChapter 509 Hospice Services — comments and resulting updates (Coverage Criteria)
    Policy CodePolicy N/A
    Change TypeClarifications and minor wording changesone material addition to eligibility language
    Effective DateMay 1, 2020
    Last ReviewMay 1, 2020
    Next Review DateN/A
    Key ActionMaintain required physician certification within the state timeline and retain documentation of referrals, plan of care/IPP, and coordination with PCS/waiver case management.
    SourceLink
    On This Page
    Coverage Criteria and ConditionsProvider Responsibilities, Documentation, and Billing AlertsKey DefinitionsBackground
    Documentation Required

    Document referrals, plan-of-care/IPP, and coordination with PCS/HCBS

    Hospice providers must ensure coordination and documentation with waiver/HCBS and PCS programs as described in the comments: maintain records of referrals, the member’s plan of care or Individual Program Plan (IPP), and evidence of coordination/case management between agencies.

    • Maintain documentation of the referral from the member’s attending physician in both the coordination/case management agency and the hospice provider records.
    • Document the need for hospice services in the member’s plan of care or IPP.
    • Ensure records reflect coordination between hospice and HCBS/PCS case management or coordination agencies.
    Denial Risk

    Physician certification timeline — 8‑day rule and reimbursement risk

    State plan requirements retain an 8‑day physician certification timeline; services furnished before written certification may be ineligible for reimbursement if the certification timeline is not met.

    • The 8‑day certification requirement from the WV State Plan was retained and not removed per commenter request.
    • Failure to obtain required written physician certification within the state‑specified timeline may render services furnished before certification ineligible for reimbursement.