Subsection 144-101-II-43.05 - COVERED SERVICES43.05-1Covered ServicesCovered hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. To be covered, all services must be in accordance with the plan of care and approved by the Interdisciplinary Team. Services unrelated to the terminal illness which affect the plan of care must be reflected in the plan in order to assure coordination and non-duplication of services.
The following are considered covered hospice services. Unless noted otherwise, reimbursement shall be based on a per diem or hourly rate, and in accordance with the provisions described in Section 43.07.
A. Physician Services (see Section 43.07-3 for further details).B. Nursing Services provided by or under the supervision of a registered nurse.C. Medical Social Services provided by a medical social worker working under the supervision of a physician.D. Counseling Services must be available to the member and family members or others caring for the member at home, including dietary, spiritual and other counseling. Counseling may be given both for the purpose of training caregivers to provide care, and for the purpose of helping the member and those caring for him or her to adjust to the member's approaching death.E. Home Health Aide Services furnished by certified home health aides and certified nursing assistants. Home health aides may provide personal care and household services essential to the comfort and cleanliness of the member and maintaining a safe and healthy environment to allow implementation of the plan of care. Aide services must be provided under the general supervision of a registered nurse. Home health aide services can include the provision of homemaker services. Homemaker services include maintenance of a safe and healthy environment and services that enable the member to carry out the plan of care.
F. Medical Supplies, Drugs and Biologicals are covered only when used primarily for the relief of pain and symptom control related to the member's terminal illness. Appliances may include covered durable medical equipment as well as other self-help and personal comfort items related to relief or management of the terminal illness. Equipment is provided by the hospice for use in the member's home while under hospice care. Medical supplies include those that are part of the written plan of care.G. Short-Term Inpatient Care provided in a participating hospice inpatient unit or a participating hospital or nursing facility which meets the special hospice standards regarding staffing and patient areas. Participating facilities are defined as those with which the hospice has a contract that provides for all requirements contained within the Medicare Hospice conditions of participation. Inpatient services must conform to the written plan of care. General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management that cannot be provided in other settings. Inpatient care may also be furnished to provide respite for individuals caring for the member at home.H. Physical, Occupational and Speech/Language Therapy provided for symptom control or to allow the member to perform daily living activities and basic functional skills.I. Special Modalities, including chemotherapy, radiation therapy, and other modalities that may be used for palliative purposes if it is determined that these services are needed for palliation. This determination is based on the member's condition and philosophy of care giving of the hospice. No additional MaineCare reimbursement shall be provided, regardless of the cost of the services.J. Ambulance Services, when the medical condition requiring ambulance transport is a result of the member's terminal illness.K. Other Items and Services specified in the plan of care for which payment may otherwise be made. This item reflects the hospice's responsibility for providing any and all services in the plan of care necessary for the relief and management of the terminal illness and related conditions.43.05 -2Special Coverage RequirementsBereavement counseling consists of counseling services provided to the member's family for up to one (1) year after the member's death. It is a required hospice service but is not separately billable.
43.05-3Room and Board Services for Nursing Facility ResidentsThe following services shall be included as room and board services and shall be provided by the nursing facility for those MaineCare members who elect to receive hospice while residing in the nursing facility:
A. Performance of personal care services;B. Assistance in activities of daily livingC. Administration of medication;D. Maintaining cleanliness of resident's room; andE. Supervising and assisting with the use of durable medical equipment and prescribed therapies.43.05-4Coverage Restrictions During Hospice ElectionA.Medically Necessary/Non-Duplicative ServicesA Member receiving hospice services may obtain other medically necessary services (as defined by the Department) that are not duplicative of hospice services or unrelated to a member's terminal illness. The provider must appropriately document services rendered in the member record, in accordance with Department specifications. These services are subject to the same coverage provisions, limitations, prior authorization requirements and conditions applied to services available to non-hospice MaineCare members. (All services, related to and unrelated to the terminal illness, must be consistent with the plan of care.) These services are reimbursable by MaineCare outside of the hospice rate.
The services include:
1. Ambulance Services - Chapter II, Section 5, when the medical condition requiring ambulance transport is unrelated to the terminal illness for which the member is receiving services under this Section.2. Speech and Hearing Services - Chapter II, Section 1093. Consumer Directed Attendant Services - Chapter II, Section 12, subject to additional restrictions that may be outlined in that Section4. Chiropractic Services - Chapter II, Section 155. Family Planning Agency Services - Chapter II, Section 306. Home Health Services - Chapter II, Section 40 subject to additional restrictions that may be outlined in that Section7. Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) Chapter II, Section 94. 8. Transportation Services - Chapter II, Section 1139. Podiatric Services - Chapter II, Section 9510. Private Duty Nursing and Personal Care Services - Chapter II, Section 96, subject to additional restrictions that may be outlined in that Section11. Behavioral Health Services - Chapter II, Section 6512. Medical Supplies and Durable Medical Equipment - Chapter II, Section 6013. Medical Imaging Services - Chapter II, Section 10114. Occupational Therapy Services - Chapter II, Section 6815. Physical Therapy Services - Chapter II, Section 85B.Continuation of ServicesIn order to maintain activities of normal life for as long as possible, certain MaineCare services may be continued after the hospice election for those members who have been receiving these services for a substantial period of time prior to the hospice election.
These services include:
1. Targeted Case Management Services - Chapter II, Section 132. Community Support Services - Chapter II, Section 173. Developmental & Behavioral Clinic Services - Chapter II, Section 234. Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations - Chapter II, Section 285. Day Health Services - Chapter II, Section 266. Rehabilitative Services - Chapter II, Section 1027. Behavioral Health Homes Services - Chapter II, Section 928. Behavioral Health Services - Chapter II, Section 659. Psychiatric Hospital Services - Outpatient services only, Chapter II, Section 4610. Opioid Health Home Services - Chapter II, Section 9311. Private Non-Medical Institution Services - Chapter II, Section 97There may be instances where it is appropriate to allow individual hospice members to receive these services even if they did not receive them prior to electing the hospice benefit. However, the provider must show that services are medically necessary given the member's terminal condition, and are coordinated with the hospice plan of care. These services are reimbursable by MaineCare outside of the hospice rate.
C.Home and Community BenefitsEligibility for and limits on home and community benefits for members of hospice care are delineated in the relevant section of Chapter II of the MaineCare Benefits Manual (MBM).
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-43, subsec. 144-101-II-43.05