Hospice Care

Hospice care involves an interdisciplinary team-oriented approach to specialized medical, psychological, and spiritual care and support provided to individuals and their families facing a life-limiting illness or injury. This specialized care focuses on caring, not curing, and on managing pain and other symptoms of illness so patients can remain as comfortable as possible near the end of life. In most cases, care is provided in the person’s home, but can also be provided in free-standing hospice centers, hospitals, nursing homes, and other long-term care facilities. The hospice team usually includes doctors, nurses, home health aides, social workers, clergy or other counselors, and trained volunteers. The team may also include speech, physical and occupational therapists, if needed. Hospice care is very individualized; the hospice team will work with the patient on his or her goals for end-of-life care.

Palliative Care

Palliative care is a specialized form of medical care focused on helping patients feel relief from the pain, symptoms, and emotional distress caused by a serious illness or its treatment. It may also be referred to as supportive care, symptom management, or comfort care. The goal of palliative care is to improve how a patient functions each day as well as improve his or her quality of life throughout the course of a serious illness, whether that illness is curable, chronic, or life-threatening. It can offer an extra layer of support and can be provided as the main goal of care or along with treatments meant to cure. Palliative care services can be appropriate at any age or at any time during a person’s illness, and can be provided in a variety of settings, including the member's home.

Providers are responsible for:

1. Verifying member eligibility and informing the plan of their intent to provide services before services are initiated.
2. Developing an individualized plan of care, and for providing covered services that are medically necessary for the management and palliation of the member's terminal illness; and
3. Notifying the plan of any significant change in the member's status (e.g., change in condition or level of care, revisions to treatment plan/goals, discharge from hospice services).

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Hospice and Palliative Services

Clinical Guideline Coverage Criteria

Home-Based Care

The plan uses InterQual® Home Care criteria to determine medical necessity and to authorize home care services, including hospice and palliative home care, after the initial evaluation visit.

In addition to InterQual criteria, the plan may authorize coverage of:

Provided under a plan of care established by and periodically reviewed by a physician.
AND

• Medically necessary and reasonable based on the Member's condition and accepted standards of clinical practice
• An integral part of treatment of the Member's medical condition and associated symptoms.

When the following are met:

1. The primary care physician or attending practitioner determines such care is reasonable and medically necessary for a terminally ill member and certifies that life expectancy is 6 months or less;
2. The Member elects or continues to elect hospice care;
3. The plan of care must be established and periodically reviewed by the attending physician, the hospice medical director, and the interdisciplinary care group of the hospice program;
4. The services are reasonable and necessary for the management and palliation of the Members terminal illness and conditions.

Note: The initial skilled nursing (SN) and/or physical therapy (PT) home care assessment/evaluation visit does not require prior authorization.

Speech therapy, occupational therapy and/or social worker visit will require prior authorization for the initial evaluation when provided independently and not in conjunction with physical therapy or skilled nursing visits. Providers requesting authorization after the initial evaluation visit must submit a thoroughly completed Universal Health Plan/Home Health Authorization Form (UHHA) to the appropriate fax number listed above.

Note: For palliative care services, evidence of homebound status is not required.

In addition to the UHHA, the requesting provider must also provide documentation of a discussion between the Member and his or her provider during which palliative care was discussed and agreed to by the Member. (Discussions with home care agency staff do not fulfill this requirement.) Updated documentation of ongoing discussions regarding palliative care status will be required every 6 months.

Continuous Hospice Care

Continuous home hospice care consists primarily of nursing care on a continuous basis in the home. Home health aide (HHA) services may also be provided on a continuous basis at home. In addition to InterQual content, coverage of continuous home care may be provided on a limited basis when the Member is experiencing a period of crisis and the continuous care is necessary to maintain the Member at home. A Member is considered to be in a period of crisis if he or she requires continuous care, which is predominantly nursing care, in order to manage acute medical symptoms or to achieve palliation.

A minimum of 8 hours of nursing and HHA care is required in a 24-hour period, which begins and ends at midnight (care hours do not need to be continuous). More than 50% of the continuous hours must be nursing care provided by either an R.N. or L.P.N.

Note: When fewer than 8 hours of nursing and HHA care are required, the care is covered as routine hospice care in the home.

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Hospice and Palliative Services
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For additional information, please consult the applicable Provider Manual for Tufts Health Plan Commercial business, Tufts Health Public Plans, or Harvard Pilgrim Health Care. You can also find important reimbursement information in our Payment Policies, which are located on the Harvard Pilgrim Health Care and Tufts Health Plan provider websites.

Facility-Based Care

Short-term inpatient care may be provided in an extend-care facility, or inpatient unit, general inpatient hospital, or a nursing facility.

The Plan considers facility-based hospice and palliative care as reasonable and medically necessary when documentation confirms ALL the following:

1. The physician and/or interdisciplinary team determine such care is reasonable and medically necessary for the management and palliation of the illness and related conditions for a Member who requires either; a. Palliative care (i.e., diagnosed with a serious, complex, and often terminal illness) OR b. Hospice care and certifies the Member has a life expectancy of 6 months or less
2. The Member requires pain control or symptoms management that cannot feasibly be provided in other settings (e.g., member requires frequent skilled nursing care intervention on all three shifts directed toward pain control and symptom management)
3. The plan of care must be established with individualized member goals and periodically reviewed by the attending physician and the interdisciplinary team
4. The care provided is consistent with the plan of care.

Note: For Respite Care – if it conforms to the written plan of care, may also be furnished to provide respite for the Member's family or other persons caring for the individual in their home up to 5 consecutive days.

Limitations:

The plan considers hospice services as not medically necessary when criteria above are not met.

Coverage for services and subsequent payment are based on the Member's benefit plan document.

Refer to the Electronic Services section of our website for our self-service channel options. Benefit specifics should be verified prior to initiating services by logging on to our website or by contacting Provider Services.

Respite care may be covered for no more than five consecutive days at a time.

• Coverage for respite care may not be provided for Members who are receiving hospice care in or who reside in a facility
• General inpatient care days are not covered in situations where the sole reason for the inpatient stay is that the Member’s caregiver support has broken down, without the guidelines for general inpatient care outlined above being met
• Residential or respite care must be for members who are terminally ill and are receiving authorized hospice care from a certified hospice provider

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