ModifiedWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

CHAPTER 509 — Hospice Services (Coverage Criteria)

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Defines West Virginia Medicaid coverage, provider participation, staffing, service types, benefit periods, and administrative requirements for hospice services for eligible West Virginia Medicaid members.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyCHAPTER 509 — Hospice Services (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMultiple additions and language updates (including SIA, background checks, reimbursement methodology)

Effective DateMay 1, 2020

Last ReviewMay 1, 2020

Next Review DateN/A

Key ActionSubmit signed physician certification, HEF-01, and Plan of Care to the UMC within eight calendar days of hospice initiation.

SourceLink

POLICY UPDATE CHANGES

Updated language throughout the entire Hospice Services chapter and added multiple new sections including Infection Control, Emergency Preparedness, out-of-state services, Service Intensity Add-on (SIA) payments, SIA payment methodology, appeals/fair hearing procedures, coordination of care and payment limits, and an MCO section.

Added Section 509.2 on Criminal Background Checks with link to WV CARES Policy (Chapter 700).

Added Service Intensity Add-on payment sections per 42 CFR §418.302 and SIA payment methodology to reimbursement procedures.

2020-05-01chapter effective date

90/90/60+Benefit periods

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ModifiedWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

CHAPTER 509 — Hospice Services (Coverage Criteria)

Customize your policy alerts

Sign up for all West Virginia Bureau for Medical Services (Department of Human Services) policy alerts

Know when West Virginia Bureau for Medical Services (Department of Human Services) releases new policies or updates existing guidance.

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Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyCHAPTER 509 — Hospice Services (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMultiple additions and language updates (including SIA, background checks, reimbursement methodology)

Effective DateMay 1, 2020

Last ReviewMay 1, 2020

Next Review DateN/A

Key ActionSubmit signed physician certification, HEF-01, and Plan of Care to the UMC within eight calendar days of hospice initiation.

SourceLink

POLICY UPDATE CHANGES

Added Section 509.2 on Criminal Background Checks with link to WV CARES Policy (Chapter 700).

Added Service Intensity Add-on payment sections per 42 CFR §418.302 and SIA payment methodology to reimbursement procedures.

2020-05-01chapter effective date

90/90/60+Benefit periods

2 / 8 daysCertification timeline

15min–4hrSIA daily range

Coverage and Medical Necessity Criteria

Covered Hospice Services

Covered when services are reasonable and necessary for palliation and management of the terminal illness and related conditions and included in an interdisciplinary plan of care.

General coverage logic: Services must be reasonable and necessary for palliation and management of the terminal illness and related conditions

Must be documented in an interdisciplinary plan of care established before care begins (see 509.3.2)

Core Hospice Services: Nursing, medical social services, physician services, and counseling (including bereavement counseling up to one year) must be provided as core services by hospice employees, contractors, or volunteers as specified

Bereavement counseling is required but not reimbursable (West Virginia State Plan Appendix 3.1-C)

Other Hospice Services: Drugs and biologicals related to palliation and management of the terminal illness and related conditions, durable medical equipment and supplies, short-term inpatient care (respite or symptom control), home health/homemaker services, and rehabilitation for symptom control or ADL maintenance may be provided or arranged by the hospice

Drugs and biologicals must be identified in the Hospice Plan of Care and provided while the member is under hospice care (see 42 CFR §418.56(c)(4), §418.106, §418.202(f))

Concurrent Care for Children

Exception to usual hospice-only limitation for pediatric members under age 21.

Pediatric concurrent care: Hospice services may be provided to children under age 21 concurrently with curative treatment in accordance with the Affordable Care Act (Concurrent Care for Children)

Service exception allowing concurrent curative therapy

Initial Enrollment and Recertification Criteria

Covered when ALL of the following are met:

Initial Certification: Physician (Hospice medical director or IDT assigned physician and attending physician for the first 90-day period) must certify that the member has a terminal illness with life expectancy of six months or less if the illness runs its normal courselife expectancy ≤ 6 months

Certification requirement per 42 CFR §418.22

Enrollment Documentation: Hospice provider must complete a Plan of Care, obtain a signed Hospice Election Form (HEF-01), document informed consent, and provide required copies to the member as requestedsigned HEF-01 and Plan of Care

Signed physician certification, HEF-01, and Plan of Care must be submitted to the UMC within eight calendar days

Certification Timeline: Obtain written physician certification no later than two calendar days after hospice care initiation; if written certification cannot be obtained within two days for the initial 90-day period, obtain oral certification within two days and written certification no later than eight calendar days after the period begins

Billing and Reimbursement Criteria

Payment and service limits for hospice categories

RHC Coverage: Routine Home Care (RHC) is paid per day (Revenue Code 0651) for each day the member is under hospice care and not receiving CHC, IRC, or GIC; unit = 1 day and limit = 1 unit per day; rate paid regardless of volume or intensity of routine services1 unit/day

RHC paid even when member receives hospital care for a condition unrelated to the terminal condition

SIA Coverage: Service Intensity Add-on (SIA) payment (billed with RHC, Revenue Code 0651) applies for RN nursing visits and social worker visits during RHC in the last seven days of life; unit = 15 minutes; minimum 15 minutes up to a maximum of 4 hours (16 units) per day combined; social worker phone calls are not eligible for SIA15 minutes–4 hours per day; max 16 units

SIA payment is in addition to the RHC rate and applies only in the last seven days of life

CHC Coverage:

Covered Levels of Hospice Care and Reimbursement

Covered hospice services and conditions for reimbursement include the following levels of care and associated rules:

SIA payment for RHC last 7 days: SIA payment is payable for RN nursing visits and social worker visits during routine home care in the last seven days of life; visits must be at least 15 minutes and up to 4 hours per day (1 to 16 15-minute units combined); social worker phone calls are not eligible≤16 units/day

SIA amount is calculated by multiplying CHC rate (per 15 minutes) by number of units and adjusted for geographic wage differences

Continuous Home Care (CHC): CHC uses Revenue Code 0652 with unit = 1 hour; billable minimum of 8 hours up to 24 hours per day; services must be predominantly nursing and reimbursement is based on hours provided8–24 hours/day

CHC provided during brief periods of crisis; home health aide or homemaker services may be included

Inpatient Respite Care (IRC):

Bereavement counseling is a required component of the hospice benefit and consists of counseling services provided to the patient’s family up to one year after the patient’s death. However, bereavement counseling is not reimbursable by West Virginia Medicaid and must not be billed as a payable hospice service. The policy also notes that volunteer-provided services offered at no charge for non-Medicaid individuals cannot be billed to Medicaid.

Hospice services do not include services furnished before or after an elected hospice period, services of the attending physician if that physician is not employed by or under arrangement with the designated hospice, or Medicaid services for treatment of illnesses or injuries unrelated to the terminal condition. Once hospice is elected, Medicaid will not reimburse other Medicaid services that treat the terminal condition except where specifically allowed (for example, concurrent care for children under age 21). Providers must ensure the member understands that electing hospice waives Medicaid coverage of services related to the terminal condition as described in the Plan of Care.

Service Intensity Add-on (SIA) payments apply only to in-person RN nursing visits and social worker visits during Routine Home Care in the last seven days of life. Social worker phone calls are explicitly excluded from SIA payment and should not be billed as SIA units.

A hospice discharge occurs when the hospice determines the patient is no longer terminally ill, the patient expires, the patient moves out of the hospice’s service area, the patient transfers to another hospice, or when patient or household behavior is disruptive, abusive, or uncooperative so as to seriously impair care delivery or hospice operations. Providers must follow the discharge reasons outlined in federal regulations and the State Plan and ensure that benefit-period and waiver effects (e.g., reinstatement of regular Medicaid coverage when election ends or discharge occurs) are managed per policy.

If a member revokes hospice services on four separate occasions, the member is administratively excluded from future hospice enrollment and is not eligible to elect hospice again. Providers should track revocations and subsequent elections to prevent re-enrollment after the fourth revocation.

Physician certification timelines are strict: obtain a written certification no later than two calendar days after hospice initiation; for the initial 90-day period, if written certification cannot be obtained within two days, obtain an oral certification within two days and the written certification no later than eight calendar days after the period begins. If these timelines are not met, services provided before the date of written certification are not eligible for reimbursement. Additionally, appropriate certification and recertification documentation must be submitted to the utilization management contractor (UMC) within eight calendar days of election.

Revenue Codes, Units, and Key Coding Details

Referenced CFR and State Plan sections (informational)mixed

42 CFR §418.56	Interdisciplinary group and plan of care requirements referenced
42 CFR §418.60	Infection control program
42 CFR §418.62	Staffing involvement
42 CFR §418.64	Staffing and IDT requirements
42 CFR §418.78	Volunteer and training requirements
42 CFR §418.100(g)	Training/in-service documentation
42 CFR §418.106	Durable medical equipment and supplies reference
42 CFR §418.113	Emergency preparedness

Routine Home Care (RHC) Revenue CodeRevenueCovered

0651	Revenue code for Routine Home Care (RHC)

Service Intensity Add-on (SIA) Revenue CodeRevenueCovered

0651	Revenue code for Service Intensity Add-on (SIA) when billed with RHC

Continuous Home Care (CHC) Revenue CodeRevenueCovered

0652	Revenue code for Continuous Home Care (CHC)

Continuous Home Care Revenue CodeRevenueCovered

0652	Continuous Home Care revenue code

Inpatient Respite Care Revenue CodeRevenueCovered

0655	Inpatient Respite Care revenue code

General Inpatient Care Revenue CodeRevenueCovered

0656	General Inpatient Care revenue code

Nursing Facility Hospice Revenue CodeRevenueCovered

0658	Nursing facility hospice room and board revenue code

Volunteer hours requirement — minimum percent of paid direct-member care hours

Volunteer hours requirementVolunteer hours must equal at least 5% of the hours of direct-member care furnished by paid personnel (employees or contractors).

Regulatory referenceUse of volunteers must comply with 42 CFR §418.78 and §418.304(b).

Billing restrictionServices provided by volunteers at no charge for non-Medicaid individuals may not be billed to Medicaid.

Benefit period lengths — initial, subsequent, subsequent 60-day

Initial benefit period

Provider Responsibilities, Documentation, and Authorization

Documentation Required

Document medications and services in the Hospice Plan of Care

Drugs, biologicals, and other hospice-provided services must be identified and documented in the interdisciplinary Hospice Plan of Care while the member is under hospice care; hospice-covered drugs are those related to palliation and management of the terminal illness and related conditions and must follow the hospice drug policies and procedures cited in 42 CFR §418 (including ordering, dispensing, administration, labeling, disposition, and storing).

List all medications and biologicals used for palliation and symptom management in the Plan of Care.
Document the type, scope, frequency, and responsible staff for each service in the interdisciplinary Plan of Care.

Prior Authorization

UMC authorization required for certifications

Obtain authorization from the utilization management contractor (UMC) for all initial certifications and subsequent recertifications; submit required enrollment and certification documentation to the UMC within eight calendar days of hospice initiation. Retrospective authorization may be granted when services begin before final authorization if the member meets program requirements.

Background and Policy Changes

Hospice provides palliative and supportive care for members with a terminal illness when curative options are exhausted or not desired. The benefit focuses on symptom palliation and comfort through an interdisciplinary plan of care that addresses physical, psychosocial, spiritual, and emotional needs. Services must be reasonable and necessary for management of the terminal illness and related conditions and are delivered by core hospice personnel (nursing, medical social services, physician services, counseling) and other arranged services documented in the Plan of Care.

Key Definitions

Hospice services definition — palliative and supportive services summary

DefinitionHospice services are reasonable and medically necessary palliative and supportive services provided to terminally ill members for the management of the terminal illness and related conditions.

Interdisciplinary plan of careAn interdisciplinary plan of care must be established before care begins and must detail the type, scope, and frequency of services to address needs of the member and family (per 42 CFR §418.56 and §418.200).

Scope of servicesIncludes core services (nursing, medical social services, physician services, counseling including bereavement) plus other services such as drugs/biologics, durable medical equipment, short-term inpatient care, home health/homemaker services, and rehabilitation for symptom control or ADL maintenance.

Core Hospice Services — list of services to be provided by hospice staff/contractors/volunteers

NursingProvided by an RN or an LPN under RN supervision; part of core hospice services to be provided directly by hospice employees/contractors/volunteers.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyCHAPTER 509 — Hospice Services (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMultiple additions and language updates (including SIA, background checks, reimbursement methodology)

Effective DateMay 1, 2020

Last ReviewMay 1, 2020

Next Review DateN/A

Key ActionSubmit signed physician certification, HEF-01, and Plan of Care to the UMC within eight calendar days of hospice initiation.

SourceLink

On This Page

written by day 2 or oral by day 2 and written by day 8

Failure to meet timeline makes services before written certification not reimbursable

Recertification Face-to-Face: For members whose total stay across hospices is anticipated to reach 180 days, a face-to-face recertification visit by a Hospice physician or Hospice APRN must occur no more than 30 calendar days prior to the 180-day recertification and prior to every subsequent recertificationface-to-face within 30 days before recertification

If the face-to-face visit is not completed as specified, the hospice must discharge the member and Medicaid will not reimburse hospice services during the discharge period

Recertification Documentation: Written narrative for 180-day and subsequent recertifications must include date of face-to-face visit, clinical findings supporting continued ≤6 month prognosis, APRN documentation submitted to certifying physician, provider signatures, and benefit period datesnarrative includes specified items

APRN findings must be signed and submitted as separate section or addendum to recertification form

Continuous Home Care (CHC) (Revenue Code 0652) is billed per hour with unit = 1 hour; service billed for a minimum of 8 hours up to 24 hours per day; services must be predominantly nursing and provided during brief periods of crisis; reimbursement is based on hours provided

Home health aide or homemaker services may be provided in addition to nursing care

IRC uses Revenue Code 0655 with unit = 1 day; short-term care in an approved facility to provide respite to family/caregivers; respite may not be reimbursed for more than five consecutive days

≤5 consecutive days

Provided in freestanding hospice, hospital, or nursing facility per 42 CFR §418.204

General Inpatient Care (GIC): GIC uses Revenue Code 0656 with unit = 1 day and service limit 1 unit per day; provided in approved facilities for pain control or acute/chronic symptom management that cannot be managed in other settings1 unit/day

Inpatient rates paid for date of admission and subsequent inpatient days; date of discharge paid at RHC rate unless member dies and care related to terminal illness

Nursing Facility Hospice billing: For nursing facility residents electing hospice, hospice bills Revenue Code 0658 (unit = 1 day); West Virginia Medicaid will remit 95% of the daily nursing facility rate to the hospice, which reimburses the facility per contract; attach computerized case mix class printout to claims1 unit/day

Reimbursement based on facility base per diem rate with Medicaid acuity adjustment

Initial 90-day period.

Subsequent benefit periodSubsequent 90-day period.

Subsequent 60-day periodsAn unlimited number of subsequent 60-day periods; available in sequence after the initial and subsequent 90-day periods.

RHC service unit — unit definition

RHC revenue code0651 (Routine Home Care).

Service unitUnit = 1 day (one unit per day).

Payment ruleRHC rate is paid for each day the member is under hospice care and not receiving CHC, IRC, or GIC; rate paid regardless of volume/intensity of routine services.

SIA service unit and limit — 15-minute units, daily limits

SIA service unitUnit = 15 minutes (revenue code 0651 when billed with RHC).

Daily limitMinimum of 15 minutes up to a maximum of 4 hours per day (i.e., 1 to 16 units combined for nursing and social worker visits).

Eligibility windowSIA applies to RN nursing visits and social worker visits during Routine Home Care in the last seven days of life; social worker phone calls are not eligible.

CHC service unit and limit — hourly billing, min/max per day

CHC revenue code0652 (Continuous Home Care).

Service unitUnit = 1 hour; billed per hour.

Daily min/maxMinimum of 8 hours up to a maximum of 24 hours per day; reimbursement based on hours provided and services must be predominantly nursing during brief periods of crisis.

SIA payment unit cap — maximum 16 units/day, 15-minute minimum visit

Maximum units per dayMaximum 16 units per day (15-minute units).

Minimum visit lengthMinimum visit is 15 minutes (one 15-minute unit).

Payment calculationSIA payment amount is calculated by multiplying the CHC rate (per 15 minutes) by the number of units for the combined visits for the day and adjusted for geographic wage differences per Medicare guidance.

Continuous Home Care minimum hours — minimum 8 hours/day

CHC minimum hoursContinuous Home Care is billable for a minimum of 8 hours per day.

CHC natureServices must be predominantly nursing care provided during brief periods of crisis.

CHC max hoursMay be provided up to 24 hours per day; reimbursement based on hours provided.

Respite consecutive day limit — maximum 5 consecutive days

Consecutive day limitInpatient Respite Care may not be reimbursed for more than five consecutive days at a time.

Service unitRevenue code 0655; unit = 1 day.

PurposeShort-term care in an approved facility to provide respite to family or other persons involved in daily care of the member.

Submit the signed and dated physician certification, HEF-01, and Plan of Care to the UMC within 8 calendar days.
If services begin prior to final authorization, request retrospective authorization when program criteria are met.

Denial Risk

Request reconsideration and follow appeals process after UMC denial

If the UMC denies prior authorization, submit a reconsideration request with additional supportive documentation to the UMC; members or providers may appeal a UMC denial to BMS and request retrospective review when eligible (e.g., back-dated medical cards or primary insurance denials).

File a reconsideration with the UMC including new or clarifying documentation.
If denial persists, the member or provider may appeal to BMS and request retrospective review per Chapter 400 guidance.

Note

Follow federal regulations and change-log guidance (42 CFR §418)

Refer to federal hospice regulations (42 CFR §418) and the chapter change log for program requirements and updates; this chapter references the CFR sections for interdisciplinary team, drug policies, and other hospice obligations but does not list separate prior authorization codes in this excerpt.

Follow 42 CFR §418 provisions cited throughout the chapter for compliance with IDT, drug handling, and other requirements.
See the change log for recent chapter additions (effective May 1, 2020).

Note

No step therapy requirements in this excerpt

No step therapy requirements are stated in this portion of the Hospice Services chapter.

Note

Follow benefit period election sequence (90/90/60+)

Benefit periods must be elected in sequence: initial 90-day period, subsequent 90-day period, then an unlimited number of subsequent 60-day periods; election order and forfeiture rules apply when a member revokes hospice coverage.

If a member revokes during a period the remainder of that period is forfeited and subsequent enrollments follow the next period in sequence.
Members who revoke hospice services four times are ineligible to enroll again.

Billing Rule

Coordinate care and verify other Medicaid authorizations

Determine whether the member is authorized to receive similar services under other Medicaid programs and coordinate with other Medicaid service providers to avoid duplication and potential disallowance of payments.

Verify member authorization under HCBS waiver programs or other Medicaid benefits before billing hospice-covered services.
Coordinate billing and service provision with other providers to prevent duplicate payment.

Note

Review change log for chapter updates effective May 1, 2020

The chapter change log documents multiple updates to the Hospice Services chapter (effective May 1, 2020) including additions such as infection control, emergency preparedness, SIA payments, appeals procedures, coordination of care, and an MCO section—providers should review change-log items for compliance implications.

Review the listed chapter updates to identify new documentation, payment, and operational requirements.

Documentation Required

Maintain interdisciplinary Plan of Care and records for audits

Maintain and retain required records, including an interdisciplinary Plan of Care that documents the type, scope, frequency of services, and responsible staff; documentation must be accessible for state and federal audits.

Ensure the Plan of Care includes detailed service descriptions, schedules, and contact information provided to the member upon request.
Keep documentation on-site and available for audits as required by provider participation rules.

Prior Authorization

Submit HEF-01, Plan of Care, physician certification, and informed consent to UMC within 8 days

Complete the signed HEF-01 (Hospice Election Form), the interdisciplinary Plan of Care, and the Hospice informed consent form and submit the signed physician certification, HEF-01, and Plan of Care to the UMC within eight calendar days of hospice initiation.

Provide copies of the Plan of Care, conditions of enrollment, and terms of revocation to the member or legal representative and obtain signatures where required.
Submit all required enrollment documentation to the UMC within 8 calendar days to obtain authorization.

Documentation Required

Include face-to-face date and clinical findings in recertification narrative

For 180-day and every subsequent recertification, include the date of the face-to-face visit and clinical findings that support a continued life expectancy of six months or less in the written narrative; APRN clinical findings must be documented and submitted to the certifying physician.

Document the face-to-face visit date, clinical findings, APRN documentation (if applicable), certifying physician signature/date, and benefit period dates in the recertification narrative.

Billing Rule

Submit nursing facility agreement, medical necessity, and financial eligibility with first claim

For hospice services provided in a nursing facility, submit an agreement between the specific nursing facility and the Hospice provider, documentation to support medical necessity for each covered service, and financial eligibility documentation to the UMC with the first claim for payment.

Attach the nursing facility–hospice agreement and supporting medical necessity documentation with the initial authorization/first claim.
Include Medicare/Medicaid financial eligibility documentation for the resident.

Denial Risk

Perform required face-to-face visit prior to 180-day recertification

If a member's total stay across hospices is anticipated to reach 180 days, a hospice physician or nurse practitioner must perform a face-to-face visit no more than 30 calendar days prior to the 180-day recertification and before every subsequent recertification; failure to complete the visit requires discharge and cessation of Medicaid reimbursement until completed.

Schedule and document face-to-face visits within the 30-day timing window prior to the 180-day recertification and prior to each subsequent recertification.
If face-to-face visit is not completed as specified, discharge the member per policy and cease billing until requirements are met.

Documentation Required

Obtain signed Hospice Informed Consent before services

Obtain a written Hospice Informed Consent signed by the member or the member's legal representative prior to initiating hospice services; the consent must specify the type and scope of care to be provided.

Provide the informed consent form detailing type and scope of care and have it signed before services begin.
Retain the signed informed consent in the member record and submit with enrollment materials as required.

Note

Maintain licensure, enrollment, and documentation to remain a participating provider

Maintain required provider participation elements—valid licensure and certifications (including CON), BMS enrollment, Medicare enrollment where applicable, and all required documentation—because failure to maintain these may jeopardize payment and program participation.

Ensure physical location in West Virginia as required for participation.
Keep documentation available for state and federal audits.

Denial Risk

Meet physician certification timelines or risk nonpayment

If physician certification timelines are not met (written certification no later than two calendar days after hospice initiation, or oral within two days and written by day eight for the initial 90‑day period), services furnished before written certification are not eligible for reimbursement.

Obtain written certification within 2 calendar days or obtain oral certification within 2 days and the written certification by day 8 for the initial period.
Do not expect reimbursement for services provided before the written certification date if timelines are missed.

Denial Risk

Complete required face-to-face recertification visits or face discharge and nonpayment

If required face-to-face recertification visits are not completed within the policy-specified timing (no more than 30 days prior to the 180-day recertification and before each subsequent recertification), the Hospice must discharge the member and Medicaid will not reimburse hospice services during the discharge period.

Complete face-to-face visits within the 30-day window to avoid forced discharge and loss of reimbursement.
Document the visit and include findings in the recertification narrative to support continued eligibility.

Prior Authorization

Provide complete enrollment and certification documents to UMC for authorization

The UMC will not approve authorization for initial or subsequent certifications without appropriate enrollment documentation (signed physician certification, HEF-01, and Plan of Care) submitted within eight calendar days; ensure provider enrollment and documentation are complete before submitting for authorization.

Confirm provider enrollment status and include all required signed documents with the UMC submission.
Expect authorization to be denied if enrollment/documentation are incomplete.

Denial Risk

Submit required nursing facility hospice documentation with first claim or risk denial

For nursing facility hospice authorizations, failure to submit the required agreement between the nursing facility and the Hospice, medical necessity documentation, and financial eligibility documentation with the first claim may result in UMC denial of authorization and reimbursement.

Attach the nursing facility–hospice agreement and supporting documentation to the initial authorization and first claim.
If denied, providers may request reconsideration and appeal per the UMC/BMS process.

Denial Risk

Secure signed informed consent before services to avoid denial

Obtain the member's or legal representative's signature on the written Hospice Informed Consent prior to service; absence of a signed consent may lead to denial of services or payment.

Ensure the informed consent specifies the type and scope of care and is signed before services commence.
Include the signed informed consent when submitting enrollment documentation to the UMC.

Medical Social ServicesProvided by an LSW working under the direction of a physician.

Physician servicesProvided by professionals acting within scope of license (MD, DO, DPM, DDS, OD, DC); medical director or IDT physician must be a licensed MD or DO.

Counseling (including Bereavement)Counseling provided to the member and family; bereavement counseling is required up to one year after death but is not reimbursable under Medicaid.

Other servicesHospice must make available non-core services (drugs/biologics related to palliation, DME/supplies, short-term inpatient care, home health/homemaker, rehabilitation) either directly or by contract.

Terminal illness (hospice) — definition and certification requirement

Terminal illness definitionA condition defined as having a life expectancy of six months or less if the illness runs its normal course (per 42 CFR §418.22).

Certification requirement for first 90 daysFor the first 90-day election period, the Hospice medical director or IDT assigned physician and the attending physician (if present) must certify and document the diagnosis and terminal illness.

Continuous Home Care (CHC) definition — predominantly nursing care during crisis, billing rules

DefinitionContinuous Home Care (CHC) is predominantly nursing care provided during brief periods of crisis and is billable per hour (revenue code 0652).

Billing rulesUnit = 1 hour; minimum 8 hours and up to 24 hours per day; reimbursement is based on number of hours provided.

Service compositionServices must be predominantly nursing; home health aide or homemaker services may be provided in addition to nursing care.

Inpatient Respite Care (IRC) definition — short-term facility respite, ≤5 days

DefinitionInpatient Respite Care (IRC) is short-term care provided in an approved facility to provide respite to family or other persons involved in daily care of the member.

Service unitRevenue code 0655; unit = 1 day.

LimitRespite care may be provided only occasionally and may not be reimbursed for more than five consecutive days at a time.

General Inpatient Care (GIC) definition — inpatient for pain/symptom control, billing notes

DefinitionGeneral Inpatient Care is inpatient care provided in an approved freestanding hospice, hospital, or nursing facility for pain control or acute/chronic symptom management that cannot be treated in another setting.

Service unit and limitRevenue code 0656; unit = 1 day; service limit 1 unit per day; inpatient rates paid for date of admission and subsequent inpatient days except date of discharge, which is paid at RHC rate unless death occurs and inpatient care was related to terminal illness.

Attending Physician definition

Attending PhysicianA doctor of medicine or osteopathy legally authorized to practice in the state who serves as the Attending Physician (per 42 CFR §418.3(1)(i)).

RoleMay be the member's attending physician who participates in certification for the first 90-day period when present.

Nurse Practitioner (NP) definition

Nurse Practitioner (NP)A nurse who meets training, education, and experience requirements and is identified by the member at election of hospice as having the most significant role in determination and delivery of medical care (per §410.75(b)).

Role in careAn NP may perform face-to-face visits and participate in recertification processes as specified in the chapter.

Bereavement Counseling definition

Bereavement Counseling — definitionEmotional, psychosocial, and spiritual support and services provided before and after the death of the member to assist with grief, loss, and adjustment (see 42 CFR §418.3).

Reimbursement noteBereavement counseling is a required hospice service but is not reimbursable under Medicaid (West Virginia State Plan Hospice Services Appendix 3.1-C).

DurationProvided to the individual's family up to one year after the individual's death.

Hospice Care definition

Hospice Care — definitionA comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill member and/or family members, as delineated in a specific patient plan of care (see 42 CFR §418.3 and Chapter 509 service requirements).

Interdisciplinary coordinationCare is planned, delivered, and coordinated by an IDT and must be documented in an interdisciplinary plan of care established before care begins.

Palliative Care definition

Palliative Care — definitionMember and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering across physical, emotional, social, and spiritual domains (see 42 CFR §418.3).

ScopeFocuses on symptom palliation and comfort when curative options are exhausted or not desired, addressing physical, psychological, psychosocial needs and facilitating member autonomy and choice.

Terminally ill definition — life expectancy ≤ 6 months

Terminally ill — definitionA medical prognosis that the patient's life expectancy is six months or less if the illness runs its normal course.

Use in eligibilityThis prognosis underlies physician certification and continued eligibility for hospice care, and must be documented by certifying physicians as required for elections and recertifications.