471 Neb. Admin. Code, ch. 36, § 004

Current through September 17, 2024

Section 471-36-004 - SERVICE REQUIREMENTS

004.01GENERAL REQUIREMENTS.

004.01(A)CLIENT ELIGIBILITY. The Medicaid hospice benefit is available to clients who meet the following criteria:

(i) The client is currently eligible for Medicaid;

(ii) The client is diagnosed as terminally ill by the hospice medical director or the physician member of the hospice interdisciplinary group (IDG), and the attending physician, if any; and

(iii) The client is an adult and has elected to receive palliative or comfort care to manage symptoms of terminal illness, and has chosen not to receive curative treatment or disease management; or

(iv) The client is a child and his or her parent or guardian has elected to receive palliative or comfort care to manage symptoms of terminal illness. Such election by a child's parent or guardian must not constitute a waiver of any rights of the child to be provided with, or receive Medicaid payment for, concurrent services related to the treatment of the child's condition for which a diagnosis of terminal illness has been made.

004.01(B)ELECTION OF HOSPICE SERVICES. A client, or the client's representative, must file a voluntary, written expression to choose hospice care, called an election statement, designating the Medicaid hospice benefit as the care preference for terminal illness. The election statement must include:

(1) The effective date for the election period that begins with the first day of hospice care or any subsequent day of hospice care. This date may not be earlier than the date the election is made;

(2) The name of the hospice provider;

(3) The client's or representative's acknowledgement that he or she has been given a full understanding of hospice care;

(4) The client's or representative's acknowledgement that he or she understands that the Medicaid services listed in this chapter are waived by the election; and

(5) The client's signature. If the client is physically or mentally incapacitated, his or her representative may file the election statement. If signed by the client's representative, the reason the client cannot sign the election statement must be documented.

004.01(B)(i)HOSPICE RESPONSIBILITIES AT ELECTIONS. When a client elects to receive hospice services, the hospice program must:

(1) Explain the scope of benefits the client must receive as a part of the hospice program;

(2) Explain the benefits the client is waiving;

(3) Give the client or legal representative a copy of the signed statement;

(4) Retain the signed statement in its files; and

(5) Inform the client of his or her rights, and the hospice must protect and promote the exercise of these rights.

004.01(B)(ii)BENEFIT PERIODS. Medicaid provides two 90-day benefit periods during the client's lifetime. If additional benefit periods are needed, Medicaid provides an unlimited number of 60-day benefit periods as elected by the client. The benefit periods may be used consecutively or at intervals. An election to receive hospice care will be considered to continue through the initial certification period and the subsequent election periods without a break in care as long as the client remains in the care of the hospice and does not revoke the election in accordance with this chapter.

004.01(B)(ii)(1)CERTIFICATION. The client must be certified as terminally ill by the hospice medical director, or the physician member of the hospice interdisciplinary group (IDG), and the attending physician, if any, at the beginning of the first benefit period, and by the hospice medical director for all subsequent benefit periods. The initial certification must be signed by both the medical director, or physician member of the hospice interdisciplinary group (IDG), and the attending physician. Subsequent certifications must include a new statement regarding life expectancy, and be signed by the attending physician.

004.01(B)(ii)(1)(a)INITIAL CERTIFICATION AND SUBSEQUENT BENEFIT PERIODS. The initial written certification must be made within two calendar days of the start of hospice care; however, if verbal certification is provided within the first two calendar days, written certification may be provided within eight days after hospice care is initiated. Additionally, the initial certification may be completed no more than 15 calendar days prior to the effective date of the election. If these time periods are not met, coverage will not be provided for hospice care rendered before certification. For subsequent benefit periods, written certification must be made within two calendar days of the start of the subsequent period. Additionally, the certification for subsequent benefit periods may be completed no more than 15 calendar days prior to the start of each subsequent benefit period.

004.01(B)(ii)(1)(b)DECLINE IN CLINICAL STATUS. Clients will be considered to have a life expectancy of six months or less only when there is documented evidence of a decline in clinical status. A requirement of the certification process for hospice is the physician narrative explanation of the clinical findings that support a life expectancy of six months or less. This brief narrative is to be part of the certification and recertification forms or as an addendum to the certification and recertification forms. Baseline data is established on admission to hospice through nursing assessment in addition to utilization of existing information from records. It is essential that baseline and follow-up determinations are documented thoroughly to establish a decline in clinical status. Coverage of hospice care for clients not meeting the guidelines may be denied.

004.01(B)(ii)(2)CONCURRENT CARE FOR CHILDREN UNDER THE AGE OF 21. Terminally ill children who are enrolled in a Medicaid or state Children's Health Insurance Plans (CHIP) hospice benefit, may receive curative and hospice services related to their terminal health condition.

004.01(B)(ii)(3)GUIDELINES FOR 180-DAY RECERTIFICATION OF HOSPICE SERVICES. A hospice physician must have a face-to-face encounter with each hospice client prior to, but no more than 30 days prior to, the beginning of the client's third benefit period, and prior to each subsequent benefit period. Failure to meet the face-to-face encounter requirements specified in this section results in a failure by the hospice to meet the client's recertification of terminal illness eligibility requirement. The client would cease to be eligible for the benefit until the face-to-face visit is completed.

004.01(B)(iii)WAIVER OF MEDICAID BENEFITS FOR ADULT CLIENTS. Upon signing the hospice election statement, an adult client must be deemed to have waived all rights to the following:

(1) Medicaid payment for treatment associated with the terminal illness;

(2) Hospice care provided by a hospice provider that was not designated by the client; and

(3) All services that are equivalent to, or duplicative of, hospice care.

004.01(B)(iii)(1)WAIVER DURATION. This waiver remains in effect for the duration of the election of hospice care. Medicaid services provided for conditions or illnesses that are unrelated to the terminal illness may be covered by Medicaid separate from the hospice benefit. These services must be based on individual assessed need and medical necessity as specified in the appropriate chapters of Title 471 NAC. If the client or representative revokes election of the Medicaid hospice benefit, Medicaid coverage of the benefits deemed to have been waived is restored.

004.01(B)(iv)REVOCATION OF ELECTION OF HOSPICE BENEFIT. A client or representative may revoke election of hospice care at any time. To revoke the election of hospice care, the client must file a document with the hospice that includes a signed statement that he or she revokes the election for Medicaid coverage of hospice care, and the date the revocation is to be effective. The client may not designate an effective date prior to the date the revocation document is signed. The individual forfeits coverage for any remaining days in that election period. The client may initiate reelection of the Medicaid hospice benefit if eligibility criteria are met.

004.01(B)(iv)(1)REVOCATION OF ELECTION. When the hospice election is ended due to revocation, the hospice must file a notice of revocation of election with Medicaid within five calendar days after the effective date of the revocation, unless it has already filed a final claim for that beneficiary.

004.01(B)(v)CHANGE OF HOSPICE. The client or representative may choose to change from one hospice provider to another hospice provider. A change of hospice provider may occur only once in each benefit period. To change the designation of hospice providers, the individual must file, with the hospice from which he or she has received care and with the newly designated hospice, a signed statement that includes the following information:

(1) Name of the hospice from which the individual has received care;

(2) Name of the hospice from which the individual plans to receive care; and

(3) Date the change is effective.

004.01(B)(vi)DUALLY ELIGIBLE. A client who is Medicare and Medicaid eligible must elect and revoke hospice care simultaneously under both the Medicare and the Medicaid program.

004.01(B)(vii)ADMISSION TO HOSPICE CARE. The hospice admits a client only on the recommendation of the medical director in consultation with, or with input from, the client's attending physician, if any.

004.01(B)(viii)ADVANCE DIRECTIVES. Medicaid-participating hospice agencies must comply with applicable state and federal requirements.

004.01(C)INITIAL ASSESSMENT. An initial assessment must be completed within 48 hours after Medicaid eligibility is established and the election statement is signed, unless the physician, client, or representative requests that the initial assessment be completed in less than 48 hours. The nurse completes the assessment to collect comprehensive information concerning the client's preferences, goals, health status, and to determine strengths, priorities, and resources. The assessment must be completed by a designated registered nurse (RN) from the hospice provider and coordinated with the client's Medicaid representative. Ongoing assessments must be completed and updated with each client visit.

004.01(D)PRIOR AUTHORIZATION. All hospice services must be prior authorized. The hospice must submit prior authorization requests to the Department within three business days of the initial assessment. Prior authorization may be retroactive for up to seven days, based on the client's entry date into the hospice program. Claims may be denied when prior authorization is not completed. Re-authorization is required for each subsequent benefit period. To request prior authorization, the hospice must submit:

(i) Agency name and provider number;

(ii) The client's Medicaid number. When the client's Medicaid eligibility is pending at the time of admission to hospice and the client later becomes eligible, the hospice agency must submit the request for prior authorization once the client is determined Medicaid eligible;

(iii) Signed election statement;

(iv) Physician certification of terminal illness;

(v) Hospice plan of care; and

(vi) List of all medications, biologicals, supplies, and equipment for which the hospice is responsible.

004.01(E)INDIVIDUALIZED HOSPICE PLAN OF CARE. An individualized hospice plan of care must be written to identify specific individual services to be provided in a coordinated and organized manner. The hospice must have up to three business days from the initial assessment to develop the plan of care, with involvement from the client, caregiver, attending physician, medical director, and hospice interdisciplinary group (IDG). The hospice plan of care must be established prior to services being provided.

004.01(E)(i)ADDITIONAL PLAN OF CARE REQUIREMENTS. The hospice plan of care must be culturally appropriate, and identify in detail the services that will address the needs identified in the assessment. The hospice plan of care must state in detail the scope and frequency of services that will meet the client's and family's needs. The care provided must be in accordance with the written plan of care. In the event of disagreement between the client and in-home caregiver, the client must make the final decision about care, service needs, preferences, and choices. The hospice interdisciplinary group (IDG), in collaboration with the client's attending physician, if any, must review, revise, and document the individualized plan as frequently as the client's condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the client's updated comprehensive assessment and must note the client's progress toward outcomes and goals specified in the plan of care.

004.01(F)COORDINATION OF CARE. The hospice provider must designate a registered nurse (RN) to coordinate the implementation of the hospice plan of care with the client's Medicaid representative. Coordination of care must include connections to needed services and resources, and must ensure that client choices and concerns are represented. Coordination requires sharing of information to prevent gaps in service, duplication of services, and duplication of payment. A request for additional Medicaid services, or a determination of denial of hospice services, for a Medicaid client by the hospice provider must be coordinated with the client's Medicaid representative. The hospice provider must notify the client's Medicaid representative when a Medicaid client elects hospice services.

004.01(G)DISCHARGE FROM HOSPICE. Coverage of the Medicaid hospice benefit depends on a physician's certification that a client is terminally ill. The client must be discharged from the Medicaid hospice benefit when the client improves or stabilizes enough that he or she no longer meets the definition of a terminal illness. The client may be re-enrolled for a new benefit period when a decline in the clinical status leads to a new certification that the client is terminally ill.

004.01(G)(i)DISCHARGE BY THE HOSPICE. A hospice provider may discharge a client if:

(a) The client moves out of the hospice's service area or transfers to another hospice;

(b) The hospice determines that the client is no longer terminally ill; or

(c) The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause, that the client's, or other persons in the client's home, behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the client, or the ability of the hospice to operate effectively, is seriously impaired. The hospice must do the following before it seeks to discharge a client for cause:

(1) Advise the client that a discharge for cause is being considered;

(2) Make a serious effort to resolve the problems presented by the client's behavior or situation;

(3) Ascertain that the client's proposed discharge is not due to the client's use of necessary hospice services; and

(4) Document the problems and efforts made to resolve the problems and enter this documentation into its medical records.

004.01(G)(i)(1)DISCHARGE ORDER. Prior to discharging a client for any reason listed in this section, the hospice must obtain a written physician's discharge order from the hospice medical director. If a client has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.

004.01(G)(ii)EFFECT OF DISCHARGE. A client, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice:

(1) Is no longer covered under Medicaid for hospice care;

(2) Resumes Medicaid coverage of benefits waived; and

(3) May at any time elect to receive hospice care if he or she is again eligible for the hospice benefit.

004.01(H)SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(I)HEALTH CHECK SERVICES. See 471 NAC 33.

004.02COVERED SERVICES. These services are offered based on individually assessed needs and choices of terminally ill clients and their families for palliative care and support. The client has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights. A hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice:

(1) Nursing services;

(2) Physician services;

(3) Medical social services;

(4) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling;

(5) Hospice aide, volunteer, and homemaker services;

(6) Medical supplies, including drugs and biologicals, and medical appliances;

(7) Physical therapy, occupational therapy, and speech language pathology services; and,

(8) Short-term inpatient care.

004.02(A)NURSING SERVICES. The hospice provider must assure that nursing services require the skills of a registered nurse (RN), or licensed practical nurse (LPN) under the supervision of a registered nurse (RN), and must be reasonable and necessary for the palliation and management of the client's terminal illness and related conditions. Services must be provided in accordance with recognized standards of practice. A nurse practitioner may serve as an attending physician. If the nurse practitioner serves as the attending physician, the nurse practitioner must comply with the requirements outlined in this chapter. The nurse practitioner may not serve as or replace the medical director or physician designee. Nursing services include, but are not limited to:

(i) Required visits by a registered nurse (RN) or licensed practical nurse (LPN) to monitor condition, provide care, and maintain comfort based on assessment of individual needs and as identified in the hospice plan of care;

(ii) At a minimum, the required visits by a registered nurse (RN) or licensed practical nurse (LPN) occur weekly, or more frequently as needed. The registered nurse (RN) must visit at least every two weeks;

(iii) Education based on the needs of the client, caregiver, and family about the changes to be expected with the dying process; the appropriate use of medications, therapies, equipment, and supplies; what hospice does and does not do; and emphasis on the importance of realistic goals;

(iv) An initial assessment;

(v) An individualized hospice plan of care; and

(vi) Coordination of care.

004.02(B)HOSPICE AIDE AND HOMEMAKER. The hospice provider must assure that hospice aide and homemaker services are provided to promote client care and comfort, and are completed at the direction of the client and caregiver based on client's individualized hospice plan of care. Services must be available and adequate to meet the needs of the client. Hospice aide and homemaker services include:

(i) Personal care services, as indicated in the client's individualized hospice plan of care and at the direction of the client and caregiver; and

(ii) Hospice aides may perform household services to maintain a safe and sanitary environment in areas of the home used by the client. Hospice aide services must be provided under the general supervision of a registered nurse (RN). Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the client's family to carry out the plan of care.

004.02(C)MEDICAL SOCIAL SERVICES. The hospice provider must assure that medical social services are provided by a certified social worker for the client, caregiver and family under the direction of the physician. Medical social services include:

(i) Crisis intervention for the client, caregiver, and family;

(ii) Psychosocial assessment to address needs identified by the client and caregiver and to develop plans for intervention;

(iii) Counseling to assist the client, caregiver, and family including children, to cope with serious illness and death;

(iv) Client advocacy to assure the client and caregiver have choices in care, and understands their right to refuse treatment;

(v) Act as a liaison between client and needed community resources;

(vi) Fostering human dignity and personal worth; and

(vii) Coordination of services with the Medicaid representative, when applicable.

004.02(D)MEDICAL EQUIPMENT AND SUPPLIES INCLUDING DRUGS AND BIOLOGICALS. The hospice is responsible for providing any and all services indicated in the plan of care as reasonable and necessary for the palliation and management of the terminal illness and related conditions. The hospice provider must assure that medical equipment and supplies, including drugs, are provided for relief of pain and symptom control related to the client's terminal illness and related conditions. This includes both prescription and over-the-counter drugs. All equipment, supplies, medications, and biologicals must be provided as prescribed by the client's physician, as needed, and at the direction of the client and caregiver, as indicated in the client's individualized hospice plan of care. These services include:

(i) Medication for the relief of pain and related symptoms;

(ii) Durable medical equipment related to palliation; and

(iii) Personal comfort items related to the palliation and management of the client's terminal illness.

004.02(E)OTHER COUNSELING SERVICES. The hospice provider must assure that other counseling services are available for the client, caregiver, and family. Services include:

(i) Dietary counseling;

(ii) Spiritual counseling. The hospice must:

(1) Advise the client and family of the service;

(2) Provide an assessment of the client's and family's spiritual needs;

(3) Provide spiritual counseling to meet these needs in accordance with the client's and family's acceptance of this service, and in a manner consistent with client and family beliefs and desires; and

(4) Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the client's spiritual needs to the best of its ability; and

(iii) Bereavement counseling provided through an organized program of bereavement services under the supervision of a qualified professional. The hospice provider must make bereavement services available to the family and other individuals in the bereavement plan of care up to one year following the death of the patient and ensure bereavement services reflect the needs of the bereaved. It is the choice of the family to accept bereavement services.

004.02(F)VOLUNTEER SERVICES. The hospice provider must sponsor a volunteer program and must assure that volunteers participate in an initial volunteer education program. Opportunities for ongoing education must be available for volunteers.

004.02(G)PHYSICIAN SERVICES. Physician services must be performed in accordance with 471 NAC 18. The services of the hospice medical director or the physician member of the hospice interdisciplinary group (IDG) must be performed by a doctor of medicine or osteopathy. Nurse practitioners may not serve as a medical director or as the physician member of the hospice interdisciplinary group (IDG). The hospice face-to-face encounter is an administrative requirement related to certifying the terminal illness.

004.02(H)PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH LANGUAGE PATHOLOGY SERVICES. The hospice provider must assure that physical therapy, occupation therapy, and speech language pathology services are provided to control symptoms, or to enable the client to maintain activities of daily living and basic functional skills. These services must be provided under the direction of the attending physician or medical director, and must be included in the hospice plan of care. The client and caregiver make the final decision regarding acceptance or refusal of a therapy program.

004.02(I)SHORT-TERM INPATIENT RESPITE CARE. May be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days.

004.02(J)MEDICAL INTERVENTIONS. The hospice provider must assure that medical interventions are provided when the interventions related to the terminal illness, either in use or planned, have been evaluated by the attending physician, hospice medical director, hospice team, client, caregiver, and family, based on the quality of life, value of the treatment to the client, and the service's congruence with the palliative care goals of the client, caregiver, family, and hospice. Planned interventions must be included in the hospice plan of care. A hospice may use chemotherapy, radiation therapy, and other modalities for palliative purposes if it determines that these services are needed. This determination is based on the client's condition and the individual hospice's caregiving philosophy. No additional Medicaid payment may be made regardless of the cost of the services.

004.02(K)HOSPICE SERVICES IN CERTAIN FACILITIES. A client who meets the eligibility requirements in this chapter and resides in an intermediate care facility for individuals with developmental disabilities (ICF/DD), a nursing facility (NF), an institution for mental disease (IMD), an assisted living facility (ALF), or a center for the developmental disabilities (CDD) may elect to receive hospice services where he or she lives. The Medicaid hospice benefit is available to Medicaid eligible persons in an institution for mental diseases (IMD) who are age 20 or younger, or 65 or older. The facility must agree to the provision of hospice services, and the hospice provider must have a signed contract with the facility before provision of hospice services.

004.02(K)(i)FACILITY REPONSIBILITIES. The facility must:

(1) Provide room and board for the client;

(2) Perform personal care;

(3) Assist with activities of daily living;

(4) Administer medications;

(5) Provide social activities;

(6) Provide housekeeping;

(7) Supervise and assist with the use of durable medical equipment and prescribed therapies; and

(8) Develop a plan of care in collaboration with the hospice provider, client, caregiver, and providers, including the case manager, service coordinator, and eligibility workers, and adhere to responsibilities outlined in the plan.

004.02(K)(ii)HOSPICE RESPONSIBILITIES. The hospice provider may not require the client to move from the facility as long as the client's needs can be appropriately and safely met. The hospice provider must:

(1) Assess the client's needs in coordination with the designated facility representative, client, and caregiver;

(2) Develop a hospice plan of care in collaboration with client, caregiver, facility caregivers, and providers, including the case manager, service coordinator, and eligibility workers, and adhere to responsibilities outlined in the hospice plan of care;

(3) Assume the professional management responsibility for ensuring the implementation of the hospice plan of care at the direction of the client and caregiver;

(4) In collaboration with the facility representative, coordinate the responsibilities of the facility and the responsibilities of the hospice provider, and document these responsibilities in all client records;

(5) Involve family and facility personnel in assisting with provision of services as designated by the hospice plan of care, and at the direction of the client and caregiver. The same level of services that would be provided in the home must be provided in the facility; and

(6) Provide social services and counseling utilizing hospice personnel. This service may not be delegated to the facility's personnel.

004.02(L)HOME AND COMMUNITY-BASED WAIVER SERVICES (HCBS). Clients who elect the hospice benefit while receiving home and community-based waiver services (HCBS) may continue to receive home and community-based waiver services (HCBS) that are based on assessed need and medical necessity. All medical services related to the terminal illness or the hospice plan of care are the responsibility of the hospice, and all services must be coordinated with the waiver services coordinator. The waiver services coordinator retains full responsibility for waiver planning and service authorization.

471 Neb. Admin. Code, ch. 36, § 004

Amended effective 6/2/2024