Idaho Admin. Code r. 16.03.10.454

Current through September 2, 2024

Section 16.03.10.454 - HOSPICE: PROCEDURAL REQUIREMENTS

01.Physician Certification. The hospice must obtain the certification that a participant is terminally ill in accordance with the following procedures:

a. For the first period of hospice coverage, the hospice must obtain, no later than two (2) calendar days after hospice care is initiated, written certification statements signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the participant's attending physician (if the participant has one). The certification must include the statement that the participant's medical prognosis is that their life expectancy is six (6) months or less and the signature(s) of the physician(s). In the event the participant's medical prognosis or the appropriateness of hospice care is questionable, the Department has the right to obtain another physician's opinion to verify a participant's medical status.

b. For any subsequent election period, the hospice must obtain, no later than two (2) calendar days after the beginning of that period, a written certification statement prepared by the medical director of the hospice or the physician member of the interdisciplinary group. The certification must include the statement that the participant's medical prognosis is that their life expectancy is six (6) months or less and the signature(s) of the physician(s).

c. The hospice must maintain the monthly certification statements for review.

d. The hospice will submit a physician listing with their provider application and update changes in the listing of physicians that are hospice employees, including physician volunteers, to the Bureau of Facility Standards. The designated hospice must also notify the Medicaid program when the designated attending physician of a participant in their care is not a hospice employee.

02.Election Procedures. If an participant elects to receive hospice care, they must file an election statement with a particular hospice. An election statement may also be filed by a legal representative or guardian per Section 15-5-312, Idaho Code.

a. An election to receive hospice care will be automatically renewed after the initial election period and through any subsequent election periods without a break in care as long as the participant remains in the care of a designated hospice and does not revoke the election.

b. A participant who elected less than eight (8) monthly election periods within the benefit period may request the availability of the remaining election periods. When the following conditions are met, the request will be granted.

i. The hospice days available did not exceed two hundred ten (210) days in the benefit period due to the loss of financial eligibility.

ii. The participant or the legal representative did not change hospices excessively per Subsection 454.05 of these rules.

iii. The participant or the legal representative did not revoke hospice election periods more than eight (8) times per Subsection 454.04 of these rules.

c. A participant may receive hospice services from the first day of hospice care or any subsequent day of hospice care, but a participant cannot designate an effective date that is earlier than the date that the election is made.

d. A participant must waive all rights to Medicaid payments for the duration of the election period of hospice care, with the following exceptions:

i. Hospice care and related services provided either directly or under arrangements by the designated hospice to the participant.

ii. Any Medicaid services that are not related or equivalent to the treatment of the terminal condition or a related condition for which hospice care was elected.

iii. Physician services provided by the participant's designated attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.

03.Election of Hospice. The election statement must include the following items of information:

a. Identification of the particular hospice that will provide care to the participant.

b. The participant's or representative's acknowledgment that they have been given a full understanding of hospice care.

c. The participant's or representative's acknowledgment that they understand that all Medicaid services except those identified in Subsection 454.02.d. of these rules, are waived by the election during the hospice benefit period.

d. The effective date of the election.

e. The signature of the participant or the representative and the date of that signature.

04.Revocation of Hospice Election. A participant or representative may revoke the election of hospice care at any time.

a. To revoke the election of hospice care, the participant must file a signed statement with the hospice that includes that the participant revokes the election for Medicaid coverage of hospice care effective as of the date of the revocation.

b. Upon revocation of the hospice election, other Medicaid coverage is reinstated.

05.Change of Hospice. A participant may at any time change their designated hospice during election periods for which they are eligible.

a. A participant may change designated hospices no more than six (6) times during the hospice benefit period.

b. The change of the designated hospice is not considered a revocation of the election. To change the designation of hospice programs, the participant must file during the monthly election period, with the hospice from which they have received care and with the newly designated hospice, a dated and signed statement that includes the following information:

i. The name of the hospice from which the participant has received care;

ii. The name of the hospice from which they plan to receive care; and

iii. The effective date of the change in hospices.

c. A change in ownership of a hospice is not considered a change in the patient's designation of a hospice, and requires no action on the patient's part.

06.Plan of Care. A plan of care must be established and reviewed at least monthly. To be covered, services must be consistent with the plan of care.

a. In establishing the initial plan of care, the member of the basic interdisciplinary group who assesses the patient's needs must meet or call at least one (1) other group member (nurse, physician, medical social worker, or counselor) before writing the initial plan of care.

b. At least one (1) of the persons involved in developing the initial plan must be a nurse or a physician. This plan must be established on the same day as the assessment if the day of assessment is to be a covered day of hospice care.

c. The other two (2) members of the basic interdisciplinary group must review the initial plan of care and provide their input to the process of establishing the plan of care within two (2) calendar days following the day of assessment; input may be provided by telephone.

Idaho Admin. Code r. 16.03.10.454

Effective March 17, 2022