[Title 42 CFR 418]
[Code of Federal Regulations (annual edition) - October 1, 2007 Edition]
[Title 42 - PUBLIC HEALTH]
[Chapter IV - CENTERS FOR MEDICARE]
[Subchapter A - GENERAL PROVISIONS]
[Part 418 - HOSPICE CARE]
[From the U.S. Government Printing Office]
42PUBLIC HEALTH32007-10-012007-10-01falseHOSPICE CARE418PART 418PUBLIC HEALTHCENTERS FOR MEDICAREGENERAL PROVISIONS
PART 418_HOSPICE CARE--Table of Contents
Subpart A_General Provision and Definitions
Sec.
418.1 Statutory basis.
418.2 Scope of part.
418.3 Definitions.
Subpart B_Eligibility, Election and Duration of Benefits
418.20 Eligibility requirements.
418.21 Duration of hospice care coverage--Election periods.
418.22 Certification of terminal illness.
418.24 Election of hospice care.
418.25 Admission to hospice care.
418.26 Discharge from hospice care.
[[Page 194]]
418.28 Revoking the election of hospice care.
418.30 Change of the designated hospice.
Subpart C_Conditions of Participation_General Provisions and
Administration
418.50 Condition of participation--General provisions.
418.52 Condition of participation--Governing body.
418.54 Condition of participation--Medical director.
418.56 Condition of participation--Professional management.
418.58 Condition of participation--Plan of care.
418.60 Condition of participation--Continuation of care.
418.62 Condition of participation--Informed consent.
418.64 Condition of participation--Inservice training.
418.66 Condition of participation--Quality assurance.
418.68 Condition of participation--Interdisciplinary group.
418.70 Condition of participation--Volunteers.
418.72 Condition of participation--Licensure.
418.74 Condition of participation--Central clinical records.
Subpart D_Conditions of Participation: Core Services
418.80 Condition of participation--Furnishing of core services.
418.82 Condition of participation--Nursing services.
418.83 Nursing services--Waiver of requirement that substantially all
nursing services be routinely provided directly by a hospice.
418.84 Condition of participation--Medical social services.
418.86 Condition of participation--Physician services.
418.88 Condition of participation--Counseling services.
Subpart E_Conditions of Participation: Other Services
418.90 Condition of participation--Furnishing of other services.
418.92 Condition of participation--Physical therapy, occupational
therapy, and speech-language pathology.
418.94 Condition of participation--Home health aide and homemaker
services.
418.96 Condition of participation--Medical supplies.
418.98 Condition of participation--Short term inpatient care.
418.100 Condition of participation--Hospices that provide inpatient care
directly.
Subpart F_Covered Services
418.200 Requirements for coverage.
418.202 Covered services.
418.204 Special coverage requirements.
418.205 Special requirements for hospice pre-election evaluation and
counseling services.
Subpart G_Payment for Hospice Care
418.301 Basic rules.
418.302 Payment procedures for hospice care.
418.304 Payment for physician and nurse practitioner services.
418.306 Determination of payment rates.
418.307 Periodic interim payments.
418.308 Limitation on the amount of hospice payments.
418.309 Hospice cap amount.
418.310 Reporting and recordkeeping requirements.
418.311 Administrative appeals.
Subpart H_Coinsurance
418.400 Individual liability for coinsurance for hospice care.
418.402 Individual liability for services that are not considered
hospice care.
418.405 Effect of coinsurance liability on Medicare payment.
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C.
1302 and 1395hh).
Source: 48 FR 56026, Dec. 16, 1983, unless otherwise noted.
Subpart A_General Provision and Definitions
Sec. 418.1 Statutory basis.
This part implements section 1861(dd) of the Social Security Act.
Section 1861(dd) specifies services covered as hospice care and the
conditions that a hospice program must meet in order to participate in
the Medicare program. The following sections of the Act are also
pertinent:
(a) Sections 1812(a) (4) and (d) of the Act specify eligibility
requirements for the individual and the benefit periods.
(b) Section 1813(a)(4) of the Act specifies coinsurance amounts.
(c) Sections 1814(a)(7) and 1814(i) of the Act contain conditions
and limitations on coverage of, and payment for, hospice care.
[[Page 195]]
(d) Sections 1862(a) (1), (6) and (9) of the Act establish limits on
hospice coverage.
[48 FR 56026, Dec. 16, 1983, as amended at 57 FR 36017, Aug. 12, 1992]
Sec. 418.2 Scope of part.
Subpart A of this part sets forth the statutory basis and scope and
defines terms used in this part. Subpart B specifies the eligibility
requirements and the benefit periods. Subpart C specifies conditions of
participation for hospices. Subpart D describes the covered services and
specifies the limits on services covered as hospice care. Subpart E
specifies the reimbursement methods and procedures. Subpart F specifies
coinsurance amounts applicable to hospice care.
Sec. 418.3 Definitions.
For purposes of this part--
Attending physician means a--(1)(i) Doctor of medicine or osteopathy
legally authorized to practice medicine and surgery by the State in
which he or she performs that function or action; or
(ii) Nurse practitioner who meets the training, education, and
experience requirements as described in Sec. 410.75 (b) of this
chapter.
(2) Is identified by the individual, at the time he or she elects to
receive hospice care, as having the most significant role in the
determination and delivery of the individual's medical care.
Bereavement counseling means counseling services provided to the
individual's family after the individual's death.
Cap period means the twelve-month period ending October 31 used in
the application of the cap on overall hospice reimbursement specified in
Sec. 418.309.
Employee means an employee (defined by section 210(j) of the Act) of
the hospice or, if the hospice is a subdivision of an agency or
organization, an employee of the agency or organization who is
appropriately trained and assigned to the hospice unit. ``Employee''
also refers to a volunteer under the jurisdiction of the hospice.
Hospice means a public agency or private organization or subdivision
of either of these that--is primarily engaged in providing care to
terminally ill individuals.
Physician means physician as defined in Sec. 410.20 of this
chapter.
Representative means an individual who has been authorized under
State law to terminate medical care or to elect or revoke the election
of hospice care on behalf of a terminally ill individual who is mentally
or physically incapacitated.
Social worker means a person who has at least a bachelor's degree
from a school accredited or approved by the Council on Social Work
Education.
Terminally ill means that the individual has a medical prognosis
that his or her life expectancy is 6 months or less if the illness runs
its normal course.
[48 FR 56026, Dec. 16, 1983, as amended at 52 FR 4499, Feb. 12, 1987; 50
FR 50834, Dec. 11, 1990; 70 FR 45144, Aug. 4, 2005; 72 FR 50227, Aug.
31, 2007]
Subpart B_Eligibility, Election and Duration of Benefits
Sec. 418.20 Eligibility requirements.
In order to be eligible to elect hospice care under Medicare, an
individual must be--
(a) Entitled to Part A of Medicare; and
(b) Certified as being terminally ill in accordance with Sec.
418.22.
Sec. 418.21 Duration of hospice care coverage--Election periods.
(a) Subject to the conditions set forth in this part, an individual
may elect to receive hospice care during one or more of the following
election periods:
(1) An initial 90-day period;
(2) A subsequent 90-day period; or
(3) An unlimited number of subsequent 60-day periods.
(b) The periods of care are available in the order listed and may be
elected separately at different times.
[55 FR 50834, Dec. 11, 1990, as amended at 57 FR 36017, Aug. 12, 1992;
70 FR 70546, Nov. 22, 2005]
[[Page 196]]
Sec. 418.22 Certification of terminal illness.
(a) Timing of certification--(1) General rule. The hospice must
obtain written certification of terminal illness for each of the periods
listed in Sec. 418.21, even if a single election continues in effect
for an unlimited number of periods, as provided in Sec. 418.24(c).
(2) Basic requirement. Except as provided in paragraph (a)(3) of
this section, the hospice must obtain the written certification before
it submits a claim for payment.
(3) Exception. If the hospice cannot obtain the written
certification within 2 calendar days, after a period begins, it must
obtain an oral certification within 2 calendar days and the written
certification before it submits a claim for payment.
(b) Content of certification. Certification will be based on the
physician's or medical director's clinical judgment regarding the normal
course of the individual's illness. The certification must conform to
the following requirements:
(1) The certification must specify that the individual's prognosis
is for a life expectancy of 6 months or less if the terminal illness
runs its normal course.
(2) Clinical information and other documentation that support the
medical prognosis must accompany the certification and must be filed in
the medical record with the written certification as set forth in
paragraph (d)(2) of this section. Initially, the clinical information
may be provided verbally, and must be documented in the medical record
and included as part of the hospice's eligibility assessment.
(c) Sources of certification. (1) For the initial 90-day period, the
hospice must obtain written certification statements (and oral
certification statements if required under paragraph (a)(3) of this
section) from--
(i) The medical director of the hospice or the physician member of
the hospice interdisciplinary group; and
(ii) The individual's attending physician, if the individual has an
attending physician. The attending physician must meet the definition of
physician specified in Sec. 410.20 of this subchapter.
(2) For subsequent periods, the only requirement is certification by
one of the physicians listed in paragraph (c)(1)(i) of this section.
(d) Maintenance of records. Hospice staff must--
(1) Make an appropriate entry in the patient's medical record as
soon as they receive an oral certification; and
(2) File written certifications in the medical record.
[55 FR 50834, Dec. 11, 1990, as amended at 57 FR 36017, Aug. 12, 1992;
70 FR 45144, Aug. 4, 2005; 70 FR 70547, Nov. 22, 2005]
Sec. 418.24 Election of hospice care.
(a) Filing an election statement. An individual who meets the
eligibility requirement of Sec. 418.20 may file an election statement
with a particular hospice. If the individual is physically or mentally
incapacitated, his or her representative (as defined in Sec. 418.3) may
file the election statement.
(b) Content of election statement. The election statement must
include the following:
(1) Identification of the particular hospice that will provide care
to the individual.
(2) The individual's or representative's acknowledgement that he or
she has been given a full understanding of the palliative rather than
curative nature of hospice care, as it relates to the individual's
terminal illness.
(3) Acknowledgement that certain Medicare services, as set forth in
paragraph (d) of this section, are waived by the election.
(4) The effective date of the election, which may be the first day
of hospice care or a later date, but may be no earlier than the date of
the election statement.
(5) The signature of the individual or representative.
(c) Duration of election. An election to receive hospice care will
be considered to continue through the initial election period and
through the subsequent election periods without a break in care as long
as the individual--
(1) Remains in the care of a hospice;
(2) Does not revoke the election; and
(3) Is not discharged from the hospice under the provisions of Sec.
418.26.
(d) Waiver of other benefits. For the duration of an election of
hospice care,
[[Page 197]]
an individual waives all rights to Medicare payments for the following
services:
(1) Hospice care provided by a hospice other than the hospice
designated by the individual (unless provided under arrangements made by
the designated hospice).
(2) Any Medicare services that are related to the treatment of the
terminal condition for which hospice care was elected or a related
condition or that are equivalent to hospice care except for services--
(i) Provided by the designated hospice:
(ii) Provided by another hospice under arrangements made by the
designated hospice; and
(iii) Provided by the individual's attending physician if that
physician is not an employee of the designated hospice or receiving
compensation from the hospice for those services.
(e) Re-election of hospice benefits. If an election has been revoked
in accordance with Sec. 418.28, the individual (or his or her
representative if the individual is mentally or physically
incapacitated) may at any time file an election, in accordance with this
section, for any other election period that is still available to the
individual.
[55 FR 50834, Dec. 11, 1990, as amended at 70 FR 70547, Nov. 22, 2005]
Sec. 418.25 Admission to hospice care.
(a) The hospice admits a patient only on the recommendation of the
medical director in consultation with, or with input from, the patient's
attending physician (if any).
(b) In reaching a decision to certify that the patient is terminally
ill, the hospice medical director must consider at least the following
information:
(1) Diagnosis of the terminal condition of the patient.
(2) Other health conditions, whether related or unrelated to the
terminal condition.
(3) Current clinically relevant information supporting all
diagnoses.
[70 FR 70547, Nov. 22, 2005]
Sec. 418.26 Discharge from hospice care.
(a) Reasons for discharge. A hospice may discharge a patient if--
(1) The patient moves out of the hospice's service area or transfers
to another hospice;
(2) The hospice determines that the patient is no longer terminally
ill; or
(3) The hospice determines, under a policy set by the hospice for
the purpose of addressing discharge for cause that meets the
requirements of paragraphs (a)(3)(i) through (a)(3)(iv) of this section,
that the patient's (or other persons in the patient's home) behavior is
disruptive, abusive, or uncooperative to the extent that delivery of
care to the patient or the ability of the hospice to operate effectively
is seriously impaired. The hospice must do the following before it seeks
to discharge a patient for cause:
(i) Advise the patient that a discharge for cause is being
considered;
(ii) Make a serious effort to resolve the problem(s) presented by
the patient's behavior or situation;
(iii) Ascertain that the patient's proposed discharge is not due to
the patient's use of necessary hospice services; and
(iv) Document the problem(s) and efforts made to resolve the
problem(s) and enter this documentation into its medical records.
(b) Discharge order. Prior to discharging a patient for any reason
listed in paragraph (a) of this section, the hospice must obtain a
written physician's discharge order from the hospice medical director.
If a patient 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.
(c) Effect of discharge. An individual, 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 Medicare for hospice care;
(2) Resumes Medicare coverage of the benefits waived under Sec.
418.24(d); and
(3) May at any time elect to receive hospice care if he or she is
again eligible to receive the benefit.
(d) Discharge planning. (1) The hospice must have in place a
discharge planning process that takes into account the prospect that a
patient's condition
[[Page 198]]
might stabilize or otherwise change such that the patient cannot
continue to be certified as terminally ill.
(2) The discharge planning process must include planning for any
necessary family counseling, patient education, or other services before
the patient is discharged because he or she is no longer terminally ill.
[70 FR 70547, Nov. 22, 2005]
Sec. 418.28 Revoking the election of hospice care.
(a) An individual or representative may revoke the individual's
election of hospice care at any time during an election period.
(b) To revoke the election of hospice care, the individual or
representative must file a statement with the hospice that includes the
following information:
(1) A signed statement that the individual or representative revokes
the individual's election for Medicare coverage of hospice care for the
remainder of that election period.
(2) The date that the revocation is to be effective. (An individual
or representative may not designate an effective date earlier than the
date that the revocation is made).
(c) An individual, upon revocation of the election of Medicare
coverage of hospice care for a particular election period--
(1) Is no longer covered under Medicare for hospice care;
(2) Resumes Medicare coverage of the benefits waived under Sec.
418.24(e)(2); and
(3) May at any time elect to receive hospice coverage for any other
hospice election periods that he or she is eligible to receive.
Sec. 418.30 Change of the designated hospice.
(a) An individual or representative may change, once in each
election period, the designation of the particular hospice from which
hospice care will be received.
(b) The change of the designated hospice is not a revocation of the
election for the period in which it is made.
(c) To change the designation of hospice programs, the individual or
representative must file, with the hospice from which care has been
received and with the newly designated hospice, a statement that
includes the following information:
(1) The name of the hospice from which the individual has received
care and the name of the hospice from which he or she plans to receive
care.
(2) The date the change is to be effective.
Subpart C_Conditions of Participation_General Provisions and
Administration
Sec. 418.50 Condition of participation--General provisions.
(a) Standard: Compliance. A hospice must maintain compliance with
the conditions of this subpart and subparts D and E of this part.
(b) Standard: Required services. A hospice must be primarily engaged
in providing the care and services described in Sec. 418.202, must
provide bereavement counseling and must--
(1) Make nursing services, physician services, and drugs and
biologicals routinely available on a 24-hour basis;
(2) Make all other covered services available on a 24-hour basis to
the extent necessary to meet the needs of individuals for care that is
reasonable and necessary for the palliation and management of terminal
illness and related conditions; and
(3) Provide these services in a manner consistent with accepted
standards of practice.
(c) Standard: Disclosure of information. The hospice must meet the
disclosure of information requirements at Sec. 420.206 of this chapter.
[48 FR 56026, Dec. 16, 1983, as amended at 55 FR 50834, Dec. 11, 1990]
Sec. 418.52 Condition of participation--Governing body.
A hospice must have a governing body that assumes full legal
responsibility for determining, implementing and monitoring policies
governing the hospice's total operation. The governing body must
designate an individual who is responsible for the day to day management
of the hospice program. The governing body must also ensure that all
services provided are
[[Page 199]]
consistent with accepted standards of practice.
Sec. 418.54 Condition of participation--Medical director.
The medical director must be a hospice employee who is a doctor of
medicine or osteopathy who assumes overall responsibility for the
medical component of the hospice's patient care program.
Sec. 418.56 Condition of participation--Professional management.
Subject to the conditions of participation pertaining to services in
Sec. Sec. 418.80 and 418.90, a hospice may arrange for another
individual or entity to furnish services to the hospice's patients. If
services are provided under arrangement, the hospice must meet the
following standards:
(a) Standard: Continuity of care. The hospice program assures the
continuity of patient/family care in home, outpatient, and inpatient
settings.
(b) Standard: Written agreement. The hospice has a legally binding
written agreement for the provision of arranged services. The agreement
includes at least the following:
(1) Identification of the services to be provided.
(2) A stipulation that services may be provided only with the
express authorization of the hospice.
(3) The manner in which the contracted services are coordinated,
supervised, and evaluated by the hospice.
(4) The delineation of the role(s) of the hospice and the contractor
in the admission process, patient/family assessment, and the
interdisciplinary group care conferences.
(5) Requirements for documenting that services are furnished in
accordance with the agreement.
(6) The qualifications of the personnel providing the services.
(c) Standard: Professional management responsibility. The hospice
retains professional management responsibility for those services and
ensures that they are furnished in a safe and effective manner by
persons meeting the qualifications of this part, and in accordance with
the patient's plan of care and the other requirements of this part.
(d) Standard: Financial responsibility. The hospice retains
responsibility for payment for services.
(e) Standard: Inpatient care. The hospice ensures that inpatient
care is furnished only in a facility which meets the requirements in
Sec. 418.98 and its arrangement for inpatient care is described in a
legally binding written agreement that meets the requirements of
paragraph (b) and that also specifies, at a minimum--
(1) That the hospice furnishes to the inpatient provider a copy of
the patient's plan of care and specifies the inpatient services to be
furnished;
(2) That the inpatient provider has established policies consistent
with those of the hospice and agrees to abide by the patient care
protocols established by the hospice for its patients;
(3) That the medical record includes a record of all inpatient
services and events and that a copy of the discharge summary and, if
requested, a copy of the medical record are provided to the hospice;
(4) The party responsible for the implementation of the provisions
of the agreement; and
(5) That the hospice retains responsibility for appropriate hospice
care training of the personnel who provide the care under the agreement.
[48 FR 56026, Dec. 16, 1983; 48 FR 57282, Dec. 29, 1983]
Sec. 418.58 Condition of participation--Plan of care.
A written plan of care must be established and maintained for each
individual admitted to a hospice program, and the care provided to an
individual must be in accordance with the plan.
(a) Standard: Establishment of plan. The plan must be established by
the attending physician, the medical director or physician designee and
interdisciplinary group prior to providing care.
(b) Standard: Review of plan. The plan must be reviewed and updated,
at intervals specified in the plan, by the attending physician, the
medical director or physician designee and interdisciplinary group.
These reviews must be documented.
(c) Standard: Content of plan. The plan must include an assessment
of the individual's needs and identification of the
[[Page 200]]
services including the management of discomfort and symptom relief. It
must state in detail the scope and frequency of services needed to meet
the patient's and family's needs.
Sec. 418.60 Condition of participation--Continuation of care.
A hospice may not discontinue or diminish care provided to a
Medicare beneficiary because of the beneficiary's inability to pay for
that care.
Sec. 418.62 Condition of participation--Informed consent.
A hospice must demonstrate respect for an individual's rights by
ensuring that an informed consent form that specifies the type of care
and services that may be provided as hospice care during the course of
the illness has been obtained for every individual, either from the
individual or representative as defined in Sec. 418.3.
Sec. 418.64 Condition of participation--Inservice training.
A hospice must provide an ongoing program for the training of its
employees.
Sec. 418.66 Condition of participation--Quality assurance.
A hospice must conduct an ongoing, comprehensive, integrated, self-
assessment of the quality and appropriateness of care provided,
including inpatient care, home care and care provided under
arrangements. The findings are used by the hospice to correct identified
problems and to revise hospice policies if necessary. Those responsible
for the quality assurance program must--
(a) Implement and report on activities and mechanisms for monitoring
the quality of patient care;
(b) Identify and resolve problems; and
(c) Make suggestions for improving patient care.
Sec. 418.68 Condition of participation--Interdisciplinary group.
The hospice must designate an interdisciplinary group or groups
composed of individuals who provide or supervise the care and services
offered by the hospice.
(a) Standard: Composition of group. The hospice must have an
interdisciplinary group or groups that include at least the following
individuals who are employees of the hospice:
(1) A doctor of medicine or osteopathy.
(2) A registered nurse.
(3) A social worker.
(4) A pastoral or other counselor.
(b) Standard: Role of group. The interdisciplinary group is
responsible for--
(1) Participation in the establishment of the plan of care;
(2) Provision or supervision of hospice care and services;
(3) Periodic review and updating of the plan of care for each
individual receiving hospice care; and
(4) Establishment of policies governing the day-to-day provision of
hospice care and services.
(c) If a hospice has more than one interdisciplinary group, it must
designate in advance the group it chooses to execute the functions
described in paragraph (b)(4) of this section.
(d) Standard: Coordinator. The hospice must designate a registered
nurse to coordinate the implementation of the plan of care for each
patient.
Sec. 418.70 Condition of participation--Volunteers.
The hospice in accordance with the numerical standards, specified in
paragraph (e) of this section, uses volunteers, in defined roles, under
the supervision of a designated hospice employee.
(a) Standard: Training. The hospice must provide appropriate
orientation and training that is consistent with acceptable standards of
hospice practice.
(b) Standard: Role. Volunteers must be used in administrative or
direct patient care roles.
(c) Standard: Recruiting and retaining. The hospice must document
active and ongoing efforts to recruit and retain volunteers.
(d) Standard: Cost saving. The hospice must document the cost
savings achieved through the use of volunteers. Documentation must
include--
(1) The identification of necessary positions which are occupied by
volunteers;
[[Page 201]]
(2) The work time spent by volunteers occupying those positions; and
(3) Estimates of the dollar costs which the hospice would have
incurred if paid employees occupied the positions identified in
paragraph (d)(1) for the amount of time specified in paragraph (d)(2).
(e) Standard: Level of activity. A hospice must document and
maintain a volunteer staff sufficient to provide administrative or
direct patient care in an amount that, at a minimum, equals 5 percent of
the total patient care hours of all paid hospice employees and contract
staff. The hospice must document a continuing level of volunteer
activity. Expansion of care and services achieved through the use of
volunteers, including the type of services and the time worked, must be
recorded.
(f) Standard: Availability of clergy. The hospice must make
reasonable efforts to arrange for visits of clergy and other members of
religious organizations in the community to patients who request such
visits and must advise patients of this opportunity.
Sec. 418.72 Condition of participation--Licensure.
The hospice and all hospice employees must be licensed in accordance
with applicable Federal, State and local laws and regulations.
(a) Standard: Licensure of program. If State or local law provides
for licensing of hospices, the hospice must be licensed.
(b) Standard: Licensure of employees. Employees who provide services
must be licensed, certified or registered in accordance with applicable
Federal or State laws.
Sec. 418.74 Condition of participation--Central clinical records.
In accordance with accepted principles of practice, the hospice must
establish and maintain a clinical record for every individual receiving
care and services. The record must be complete, promptly and accurately
documented, readily accessible and systematically organized to
facilitate retrieval.
(a) Standard: Content. Each clinical record is a comprehensive
compilation of information. Entries are made for all services provided.
Entries are made and signed by the person providing the services. The
record includes all services whether furnished directly or under
arrangements made by the hospice. Each individual's record contains--
(1) The initial and subsequent assessments;
(2) The plan of care;
(3) Identification data;
(4) Consent and authorization and election forms;
(5) Pertinent medical history; and
(6) Complete documentation of all services and events (including
evaluations, treatments, progress notes, etc.).
(b) Standard; Protection of information. The hospice must safeguard
the clinical record against loss, destruction and unauthorized use.
Subpart D_Conditions of Participation: Core Services
Sec. 418.80 Condition of participation--Furnishing of core services.
Except as permitted in Sec. 418.83, a hospice must ensure that
substantially all the core services described in this subpart are
routinely provided directly by hospice employees. A hospice may use
contracted staff if necessary to supplement hospice employees in order
to meet the needs of patients during periods of peak patient loads or
under extraordinary circumstances. If contracting is used, the hospice
must maintain professional, financial, and administrative responsibility
for the services and must assure that the qualifications of staff and
services provided meet the requirements specified in this subpart.
[52 FR 7416, Mar. 11, 1987, as amended at 55 FR 50835, Dec. 11, 1990]
Sec. 418.82 Condition of participation--Nursing services.
The hospice must provide nursing care and services by or under the
supervision of a registered nurse.
(a) Nursing services must be directed and staffed to assure that the
nursing needs of patients are met.
(b) Patient care responsibilities of nursing personnel must be
specified.
(c) Services must be provided in accordance with recognized
standards of practice.
[[Page 202]]
Sec. 418.83 Nursing services--Waiver of requirement that substantially all nursing services be routinely provided directly by a hospice.
(a) CMS may approve a waiver of the requirement in Sec. 418.80 for
nursing services provided by a hospice which is located in a non-
urbanized area. The location of a hospice that operates in several areas
is considered to be the location of its central office. The hospice must
provide evidence that it was operational on or before January 1, 1983,
and that it made a good faith effort to hire a sufficient number of
nurses to provide services directly. CMS bases its decision as to
whether to approve a waiver application on the following:
(1) The current Bureau of the Census designations for determining
non-urbanized areas.
(2) Evidence that a hospice was operational on or before January 1,
1983 including:
(i) Proof that the organization was established to provide hospice
services on or before January 1, 1983;
(ii) Evidence that hospice-type services were furnished to patients
on or before January 1, 1983; and
(iii) Evidence that the hospice care was a discrete activity rather
than an aspect of another type of provider's patient care program on or
before January 1, 1983.
(3) Evidence that a hospice made a good faith effort to hire nurses,
including:
(i) Copies of advertisements in local newspapers that demonstrate
recruitment efforts;
(ii) Job descriptions for nurse employees;
(iii) Evidence that salary and benefits are competitive for the
area; and
(iv) Evidence of any other recruiting activities (e.g., recruiting
efforts at health fairs and contacts with nurses at other providers in
the area);
(b) Any waiver request is deemed to be granted unless it is denied
within 60 days after it is received.
(c) Waivers will remain effective for one year at a time.
(d) CMS may approve a maximum of two one-year extensions for each
initial waiver. If a hospice wishes to receive a one-year extension, the
hospice must submit a certification to CMS, prior to the expiration of
the waiver period, that the employment market for nurses has not changed
significantly since the time the initial waiver was granted.
[52 FR 7416, Mar. 11, 1987]
Sec. 418.84 Condition of participation--Medical social services.
Medical social services must be provided by a qualified social
worker, under the direction of a physician.
Sec. 418.86 Condition of participation--Physician services.
In addition to palliation and management of terminal illness and
related conditions, physician employees of the hospice, including the
physician member(s) of the interdisciplinary group, must also meet the
general medical needs of the patients to the extent that these needs are
not met by the attending physician.
Sec. 418.88 Condition of participation--Counseling services.
Counseling services must be available to both the individual and the
family. Counseling includes bereavement counseling, provided after the
patient's death as well as dietary, spiritual and any other counseling
services for the individual and family provided while the individual is
enrolled in the hospice.
(a) Standard: Bereavement counseling. There must be an organized
program for the provision of bereavement services under the supervision
of a qualified professional. The plan of care for these services should
reflect family needs, as well as a clear delineation of services to be
provided and the frequency of service delivery (up to one year following
the death of the patient). A special coverage provision for bereavement
counseling is specified Sec. 418.204(c).
(b) Standard: Dietary counseling. Dietary counseling, when required,
must be provided by a qualified individual.
(c) Standard: Spiritual counseling. Spiritual counseling must
include notice to patients as to the availability of clergy as provided
in Sec. 418.70(f).
(d) Standard: Additional counseling. Counseling may be provided by
other members of the interdisciplinary group
[[Page 203]]
as well as by other qualified professionals as determined by the
hospice.
Subpart E_Conditions of Participation: Other Services
Sec. 418.90 Condition of participation--Furnishing of other services.
A hospice must ensure that the services described in this subpart
are provided directly by hospice employees or under arrangements made by
the hospice as specified in Sec. 418.56.
[48 FR 56026, Dec. 16, 1983, as amended at 55 FR 50835, Dec. 11, 1990]
Sec. 418.92 Condition of participation--Physical therapy, occupational therapy, and speech-language pathology.
(a) Physical therapy services, occupational therapy services, and
speech-language patholgy services must be available, and when provided,
offered in a manner consistent with accepted standards of practice.
(b)(1) If the hospice engages in laboratory testing outside of the
context of assisting an individual in self-administering a test with an
appliance that has been cleared for that purpose by the FDA, such
testing must be in compliance with all applicable requirements of part
493 of this chapter.
(2) If the hospice chooses to refer specimens for laboratory testing
to another laboratory, the referral laboratory must be certified in the
appropriate specialties and subspecialties of services in accordance
with the applicable requirements of part 493 of this chapter.
[57 FR 7135, Feb. 28, 1992]
Sec. 418.94 Condition of participation--Home health aide and homemaker services.
Home health aide and homemaker services must be available and
adequate in frequency to meet the needs of the patients. A home health
aide is a person who meets the training, attitude and skill requirements
specified in Sec. 484.36 of this chapter.
(a) Standard: Supervision. A registered nurse must visit the home
site at least every two weeks when aide services are being provided, and
the visit must include an assessment of the aide services.
(b) Standard: Duties. Written instructions for patient care are
prepared by a registered nurse. Duties include, but may not be limited
to, the duties specified in Sec. 484.36(c) of this chapter.
[48 FR 56026, Dec. 16, 1983, as amended at 55 FR 50835, Dec. 11, 1990]
Sec. 418.96 Condition of participation--Medical supplies.
Medical supplies and appliances including drugs and biologicals,
must be provided as needed for the palliation and management of the
terminal illness and related conditions.
(a) Standard: Administration. All drugs and biologicals must be
administered in accordance with accepted standards of practice.
(b) Standard: Controlled drugs in the patient's home. The hospice
must have a policy for the disposal of controlled drugs maintained in
the patient's home when those drugs are no longer needed by the patient.
(c) Standard: Administration of drugs and biologicals. Drugs and
biologicals are administered only by the following individuals:
(1) A licensed nurse or physician.
(2) An employee who has completed a State-approved training program
in medication administration.
(3) The patient if his or her attending physician has approved.
(4) Any other individual in accordance with applicable State and
local laws. The persons, and each drug and biological they are
authorized to administer, must be specified in the patient's plan of
care.
Sec. 418.98 Condition of participation--Short term inpatient care.
Inpatient care must be available for pain control, symptom
management and respite purposes, and must be provided in a participating
Medicare or Medicaid facility.
(a) Standard: Inpatient care for symptom control. Inpatient care for
pain control and symptom management must be provided in one of the
following:
(1) A hospice that meets the condition of participation for
providing inpatient care directly as specified in Sec. 418.100.
[[Page 204]]
(2) A hospital or an SNF that also meets the standards specified in
Sec. 418.100 (a) and (e) regarding 24-hour nursing service and patient
areas.
(b) Standard: Inpatient care for respite purposes. Inpatient care
for respite purposes must be provided by one of the following:
(1) A provider specified in paragraph (a) of this section.
(2) An ICF that also meets the standards specified in Sec. 418.100
(a) and (e) regarding 24-hour nursing service and patient areas.
(c) Standard: Inpatient care limitation. The total number of
inpatient days used by Medicare beneficiaries who elected hospice
coverage in any 12-month period preceding a certification survey in a
particular hospice may not exceed 20 percent of the total number of
hospice days for this group of beneficiaries.
(d) Standard: Exemption from limitation. Until October 1, 1986, any
hospice that began operation before January 1, 1975 is not subject to
the limitation specified in paragraph (c).
[48 FR 56026, Dec. 16, 1983, as amended at 55 FR 50835, Dec. 11, 1990]
Sec. 418.100 Condition of participation Hospices that provide inpatient care directly.
A hospice that provides inpatient care directly must comply with all
of the following standards.
(a) Standard: Twenty-four-hour nursing services. (1) The facility
provides 24-hour nursing services which are sufficient to meet total
nursing needs and which are in accordance with the patient plan of care.
Each patient receives treatments, medications, and diet as prescribed,
and is kept comfortable, clean, well-groomed, and protected from
accident, injury, and infection.
(2) Each shift must include a registered nurse who provides direct
patient care.
(b) Standard: Disaster preparedness. The hospice has an acceptable
written plan, periodically rehearsed with staff, with procedures to be
followed in the event of an internal or external disaster and for the
care of casualties (patients and personnel) arising from such disasters.
(c) Standard: Health and safety laws. The hospice must meet all
Federal, State, and local laws, regulations, and codes pertaining to
health and safety, such as provisions regulating--
(1) Construction, maintenance, and equipment for the hospice;
(2) Sanitation;
(3) Communicable and reportable diseases; and
(4) Post mortem procedures.
(d) Standard: Fire protection. (1) Except as otherwise provided in
this section--
(i) The hospice must meet the provisions applicable to nursing homes
of the 2000 edition of the Life Safety Code of the National Fire
Protection Association. The Director of the Office of the Federal
Register has approved the NFPA 101 [reg] 2000 edition of the
Life Safety Code, issued January 14, 2000, for incorporation by
reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy
of the Code is available for inspection at the CMS Information Resource
Center, 7500 Security Boulevard, Baltimore, MD or at the National
Archives and Records Administration (NARA). For information on the
availability of this material at NARA, call 202-741-6030, or go to:
http://www.archives.gov/federal--register/code--of--federal--
regulations/ibr--locations.html. Copies may be obtained from the
National Fire Protection Association, 1 Batterymarch Park, Quincy, MA
02269. If any changes in this edition of the Code are incorporated by
reference, CMS will publish notice in the Federal Register to announce
the changes.
(ii) Chapter 19.3.6.3.2, exception number 2 of the adopted edition
of the LSC does not apply to a hospice.
(2) In consideration of a recommendation by the State survey agency,
CMS may waive, for periods deemed appropriate, specific provisions of
the Life Safety Code which, if rigidly applied would result in
unreasonable hardship for the hospice, but only if the waiver would not
adversely affect the health and safety of the patients.
(3) The provisions of the adopted edition of the Life Safety Code do
not apply in a State if CMS finds that a fire and safety code imposed by
State
[[Page 205]]
law adequately protects patients in hospices.
(4) Beginning March 13, 2006, a hospice must be in compliance with
Chapter 9.2.9, Emergency Lighting.
(5) Beginning March 13, 2006, Chapter 19.3.6.3.2, exception number 2
does not apply to hospices.
(6) Notwithstanding any provisions of the 2000 edition of the Life
Safety Code to the contrary, a hospice may place alcohol-based hand rub
dispensers in its facility if--
(i) Use of alcohol-based hand rub dispensers does not conflict with
any State or local codes that prohibit or otherwise restrict the
placement of alcohol-based hand rub dispensers in health care
facilities;
(ii) The dispensers are installed in a manner that minimizes leaks
and spills that could lead to falls;
(iii) The dispensers are installed in a manner that adequately
protects against inappropriate access;
(iv) The dispensers are installed in accordance with chapter
18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety
Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued
by the Standards Council of the National Fire Protection Association on
April 15, 2004. The Director of the Office of the Federal Register has
approved NFPA Temporary Interim Amendment 00-1(101) for incorporation by
reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy
of the amendment is available for inspection at the CMS Information
Resource Center, 7500 Security Boulevard, Baltimore, MD and at the
Office of the Federal Register, 800 North Capitol Street NW., Suite 700,
Washington, DC. Copies may be obtained from the National Fire Protection
Association, 1 Batterymarch Park, Quincy, MA 02269; and
(v) The dispensers are maintained in accordance with dispenser
manufacturer guidelines.
(e) Standard: Patient areas. (1) The hospice must design and equip
areas for the comfort and privacy of each patient and family members.
(2) The hospice must have--
(i) Physical space for private patient/family visiting;
(ii) Accommodations for family members to remain with the patient
throughout the night;
(iii) Accommodations for family privacy after a patient's death; and
(iv) Decor which is homelike in design and function.
(3) Patients must be permitted to receive visitors at any hour,
including small children.
(f) Standard: Patient rooms and toilet facilities. Patient rooms are
designed and equipped for adequate nursing care and the comfort and
privacy of patients.
(1) Each patient's room must--
(i) Be equipped with or conveniently located near toilet and bathing
facilities;
(ii) Be at or above grade level;
(iii) Contain a suitable bed for each patient and other appropriate
furniture;
(iv) Have closet space that provides security and privacy for
clothing and personal belongings;
(v) Contain no more than four beds;
(vi) Measure at least 100 square feet for a single patient room or
80 square feet for each patient for a multipatient room; and
(vii) Be equipped with a device for calling the staff member on
duty.
(2) For an existing building, CMS may waive the space and occupancy
requirements of paragraphs (f)(1) (v) and (vi) of this section for as
long as it is considered appropriate if it finds that--
(i) The requirements would result in unreasonable hardship on the
hospice if strictly enforced; and
(ii) The waiver serves the particular needs of the patients and does
not adversely affect their health and safety.
(g) Standard: Bathroom facilities. The hospice must--
(1) Provide an adequate supply of hot water at all times for patient
use; and
(2) Have plumbing fixtures with control valves that automatically
regulate the temperature of the hot water used by patients.
(h) Standard: Linen. The hospice has available at all times a
quantity of linen essential for proper care and comfort of patients.
Linens are handled, stored, processed, and transported in such a manner
as to prevent the spread of infection.
[[Page 206]]
(i) Standard: Isolation areas. The hospice must make provision for
isolating patients with infectious diseases.
(j) Standard: Meal service, menu planning, and supervision. The
hospice must--
(1) Serve at least three meals or their equivalent each day at
regular times, with not more than 14 hours between a substantial evening
meal and breakfast;
(2) Procure, store, prepare, distribute, and serve all food under
sanitary conditions;
(3) Have a staff member trained or experienced in food management or
nutrition who is responsible for--
(i) Planning menus that meet the nutritional needs of each patient,
following the orders of the patient's physician and, to the extent
medically possible, the recommended dietary allowances of the Food and
Nutrition Board of the National Research Council, National Academy of
Sciences (Recommended Dietary Allowances (9th ed., 1981) is available
from the Printing and Publications Office, National Academy of Sciences,
Washington, DC 20418); and
(ii) Supervising the meal preparation and service to ensure that the
menu plan is followed; and
(4) If the hospice has patients who require medically prescribed
special diets, have the menus for those patients planned by a
professionally qualified dietitian and supervise the preparation and
serving of meals to ensure that the patient accepts the special diet.
(k) Standard: Pharmaceutical services. The hospice provides
appropriate methods and procedures for the dispensing and administering
of drugs and biologicals. Whether drugs and biologicals are obtained
from community or institutional pharmacists or stocked by the facility,
the facility is responsible for drugs and biologicals for its patients,
insofar as they are covered under the program and for ensuring that
pharmaceutical services are provided in accordance with accepted
professional principles and appropriate Federal, State, and local laws.
(See Sec. 405.1124(g), (h), and (i) of this chapter.)
(1) Licensed pharmacist. The hospice must--
(i) Employ a licensed pharmacist; or
(ii) Have a formal agreement with a licensed pharmacist to advise
the hospice on ordering, storage, administration, disposal, and
recordkeeping of drugs and biologicals.
(2) Orders for medications. (i) A physician must order all
medications for the patient.
(ii) If the medication order is verbal--
(A) The physician must give it only to a licensed nurse, pharmacist,
or another physician; and
(B) The individual receiving the order must record and sign it
immediately and have the prescribing physician sign it in a manner
consistent with good medical practice.
(3) Administering medications. Medications are administered only by
one of the following individuals:
(i) A licensed nurse or physician.
(ii) An employee who has completed a State-approved training program
in medication administration.
(iii) The patient if his or her attending physician has approved.
(4) Control and accountability. The pharmaceutical service has
procedures for control and accountability of all drugs and biologicals
throughout the facility. Drugs are dispensed in compliance with Federal
and State laws. Records of receipt and disposition of all controlled
drugs are maintained in sufficient detail to enable an accurate
reconciliation. The pharmacist determines that drug records are in order
and that an account of all controlled drugs is maintained and
reconciled.
(5) Labeling of drugs and biologicals. The labeling of drugs and
biologicals is based on currently accepted professional principles, and
includes the appropriate accessory and cautionary instructions, as well
as the expiration date when applicable.
(6) Storage. In accordance with State and Federal laws, all drugs
and biologicals are stored in locked compartments under proper
temperature controls and only authorized personnel have access to the
keys. Separately locked compartments are provided for storage of
controlled drugs listed in Schedule II of the Comprehensive Drug Abuse
Prevention & Control Act of 1970 and other drugs subject to abuse,
except under single unit package drug
[[Page 207]]
distribution systems in which the quantity stored is minimal and a
missing dose can be readily detected. An emergency medication kit is
kept readily available.
(7) Drug disposal. Controlled drugs no longer needed by the patient
are disposed of in compliance with State requirements. In the absence of
State requirements, the pharmacist and a registered nurse dispose of the
drugs and prepare a record of the disposal.
[48 FR 56026, Dec. 16, 1983; 48 FR 57282, Dec. 29, 1983; 49 FR 23010,
June 1, 1984, as amended at 53 FR 11509, Apr. 7, 1988; 55 FR 50835, Dec.
11, 1990; 68 FR 1386, Jan. 10, 2003; 69 FR 18803, Apr. 9, 2004; 69 FR
49266, Aug. 11, 2004; 70 FR 15237, Mar. 25, 2005; 71 FR 55339, Sept. 22,
2006]
Subpart F_Covered Services
Sec. 418.200 Requirements for coverage.
To be covered, hospice services must meet the following
requirements. They must be reasonable and necessary for the palliation
or management of the terminal illness as well as related conditions. The
individual must elect hospice care in accordance with Sec. 418.24 and a
plan of care must be established as set forth in Sec. 418.58 before
services are provided. The services must be consistent with the plan of
care. A certification that the individual is terminally ill must be
completed as set forth in Sec. 418.22.
Sec. 418.202 Covered services.
All services must be performed by appropriately qualified personnel,
but it is the nature of the service, rather than the qualification of
the person who provides it, that determines the coverage category of the
service. The following services are covered hospice services:
(a) Nursing care provided by or under the supervision of a
registered nurse.
(b) Medical social services provided by a social worker under the
direction of a physician.
(c) Physicians' services performed by a physician as defined in
Sec. 410.20 of this chapter except that the services of the hospice
medical director or the physician member of the interdisciplinary group
must be performed by a doctor of medicine or osteopathy.
(d) Counseling services provided to the terminally ill individual
and the family members or other persons caring for the individual at
home. Counseling, including dietary counseling, may be provided both for
the purpose of training the individual's family or other caregiver to
provide care, and for the purpose of helping the individual and those
caring for him or her to adjust to the individual's approaching death.
(e) Short-term inpatient care provided in a participating hospice
inpatient unit, or a participating hospital or SNF, that additionally
meets the standards in Sec. 418.202 (a) and (e) regarding staffing and
patient areas. Services provided in an inpatient setting must conform to
the written plan of care. Inpatient care may be required for procedures
necessary for pain control or acute or chronic symptom management.
Inpatient care may also be furnished as a means of providing respite for
the individual's family or other persons caring for the individual at
home. Respite care must be furnished as specified in Sec. 418.98(b).
Payment for inpatient care will be made at the rate appropriate to the
level of care as specified in Sec. 418.302.
(f) Medical appliances and supplies, including drugs and
biologicals. Only drugs as defined in section 1861(t) of the Act and
which are used primarily for the relief of pain and symptom control
related to the individual's terminal illness are covered. Appliances may
include covered durable medical equipment as described in Sec. 410.38
of this chapter as well as other self-help and personal comfort items
related to the palliation or management of the patient's terminal
illness. Equipment is provided by the hospice for use in the patient's
home while he or she is under hospice care. Medical supplies include
those that are part of the written plan of care.
(g) Home health aide services furnished by qualified aides as
designated in Sec. 418.94 and homemaker services. Home health aides may
provide personal care services as defined in Sec. 409.45(b) of this
chapter. Aides may perform household services to maintain a safe and
sanitary environment in areas of the home used by the patient, such as
changing
[[Page 208]]
bed linens or light cleaning and laundering essential to the comfort and
cleanliness of the patient. Aide services must be provided under the
general supervision of a registered nurse. Homemaker services may
include assistance in maintenance of a safe and healthy environment and
services to enable the individual to carry out the treatment plan.
(h) Physical therapy, occupational therapy and speech-language
pathology services in addition to the services described in Sec. 409.33
(b) and (c) of this chapter provided for purposes of symptom control or
to enable the patient to maintain activities of daily living and basic
functional skills.
(i) Effective April 1, 1998, any other service that is specified in
the patient's plan of care as reasonable and necessary for the
palliation and management of the patient's terminal illness and related
conditions and for which payment may otherwise be made under Medicare.
[48 FR 56026, Dec. 16, 1983, as amended at 51 FR 41351, Nov. 14, 1986;
55 FR 50835, Dec. 11, 1990; 59 FR 65498, Dec. 20, 1994; 70 FR 70547,
Nov. 22, 2005]
Sec. 418.204 Special coverage requirements.
(a) Periods of crisis. Nursing care may be covered on a continuous
basis for as much as 24 hours a day during periods of crisis as
necessary to maintain an individual at home. Either homemaker or home
health aide services or both may be covered on a 24-hour continuous
basis during periods of crisis but care during these periods must be
predominantly nursing care. A period of crisis is a period in which the
individual requires continuous care to achieve palliation or management
of acute medical symptoms.
(b) Respite care. (1) Respite care is short-term inpatient care
provided to the individual only when necessary to relieve the family
members or other persons caring for the individual.
(2) Respite care may be provided only on an occasional basis and may
not be reimbursed for more than five consecutive days at a time.
(c) Bereavement counseling. Bereavement counseling is a required
hospice service but it is not reimbursable.
[48 FR 56026, Dec. 16, 1983, as amended at 55 FR 50835, Dec. 11, 1990]
Sec. 418.205 Special requirements for hospice pre-election evaluation and counseling services.
(a) Definition. As used in this section the following definition
applies.
Terminal illness has the same meaning as defined in Sec. 418.3.
(b) General. Effective January 1, 2005, payment for hospice pre-
election evaluation and counseling services as specified in Sec.
418.304(d) may be made to a hospice on behalf of a Medicare beneficiary
if the requirements of this section are met.
(1) The beneficiary. The beneficiary:
(i) Has been diagnosed as having a terminal illness as defined in
Sec. 418.3.
(ii) Has not made a hospice election.
(iii) Has not previously received hospice pre-election evaluation
and consultation services specified under this section.
(2) Services provided. The hospice pre-election services include an
evaluation of an individual's need for pain and symptom management and
counseling regarding hospice and other care options. In addition, the
services may include advising the individual regarding advanced care
planning.
(3) Provision of pre-election hospice services. (i) The services
must be furnished by a physician.
(ii) The physician furnishing these services must be an employee or
medical director of the hospice billing for this service.
(iii) The services cannot be furnished by hospice personnel other
than employed physicians, such as but not limited to nurse
practitioners, nurses, or social workers, physicians under contractual
arrangements with the hospice or by the beneficiary's physician, if that
physician is not an employee of the hospice.
(iv) If the beneficiary's attending physician is also the medical
director or a physician employee of the hospice, the attending physician
may not provide nor may the hospice bill for this service because that
physician already possesses the expertise necessary to
[[Page 209]]
furnish end-of-life evaluation and management, and counseling services.
(4) Documentation. (i) If the individual's physician initiates the
request for services of the hospice medical director or physician,
appropriate documentation is required.
(ii) The request or referral must be in writing, and the hospice
medical director or physician employee is expected to provide a written
note on the patient's medical record.
(iii) The hospice agency employing the physician providing these
services is required to maintain a written record of the services
furnished.
(iv) If the services are initiated by the beneficiary, the hospice
agency is required to maintain a record of the services and
documentation that communication between the hospice medical director or
physician and the beneficiary's physician occurs, with the beneficiary's
permission, to the extent necessary to ensure continuity of care.
[69 FR 66425, Nov. 15, 2004]
Subpart G_Payment for Hospice Care
Sec. 418.301 Basic rules.
(a) Medicare payment for covered hospice care is made in accordance
with the method set forth in Sec. 418.302.
(b) Medicare reimbursement to a hospice in a cap period is limited
to a cap amount specified in Sec. 418.309.
(c) The hospice may not charge a patient for services for which the
patient is entitled to have payment made under Medicare or for services
for which the patient would be entitled to payment, as described in
Sec. 489.21 of this chapter.
[48 FR 56026, Dec. 16, 1983, as amended at 56 FR 26919, June 12, 1991;
70 FR 70547, Nov. 22, 2005]
Sec. 418.302 Payment procedures for hospice care.
(a) CMS establishes payment amounts for specific categories of
covered hospice care.
(b) Payment amounts are determined within each of the following
categories:
(1) Routine home care day. A routine home care day is a day on which
an individual who has elected to receive hospice care is at home and is
not receiving continuous care as defined in paragraph (b)(2) of this
section.
(2) Continuous home care day. A continuous home care day is a day on
which an individual who has elected to receive hospice care is not in an
inpatient facility and receives hospice care consisting predominantly of
nursing care on a continuous basis at home. Home health aide or
homemaker services or both may also be provided on a continuous basis.
Continuous home care is only furnished during brief periods of crisis as
described in Sec. 418.204(a) and only as necessary to maintain the
terminally ill patient at home.
(3) Inpatient respite care day. An inpatient respite care day is a
day on which the individual who has elected hospice care receives care
in an approved facility on a short-term basis for respite.
(4) General inpatient care day. A general inpatient care day is a
day on which an individual who has elected hospice care receives general
inpatient care in an inpatient facility for pain control or acute or
chronic symptom management which cannot be managed in other settings.
(c) The payment amounts for the categories of hospice care are fixed
payment rates that are established by CMS in accordance with the
procedures described in Sec. 418.306. Payment rates are determined for
the following categories:
(1) Routine home care.
(2) Continuous home care.
(3) Inpatient respite care.
(4) General inpatient care.
(d)(1) The intermediary reimburses the hospice its appropriate
payment amount for each day for which an eligible Medicare beneficiary
is under the hospice's care.
(2) Effective December 8, 2003, if a hospice makes arrangements with
another hospice to provide services under the circumstances specified in
section 1861(dd)(5)(D) of the Act, the intermediary reimburses the
hospice for which the beneficiary has made an election as described in
paragraph (d)(1) of this section.
(e) The intermediary makes payment according to the following
procedures:
[[Page 210]]
(1) Payment is made to the hospice for each day during which the
beneficiary is eligible and under the care of the hospice, regardless of
the amount of services furnished on any given day.
(2) Payment is made for only one of the categories of hospice care
described in Sec. 418.302(b) for any particular day.
(3) On any day on which the beneficiary is not an inpatient, the
hospice is paid the routine home care rate, unless the patient receives
continuous care as defined in paragraph (b)(2) of this section for a
period of at least 8 hours. In that case, a portion of the continuous
care day rate is paid in accordance with paragraph (e)(4) of this
section.
(4) The hospice payment on a continuous care day varies depending on
the number of hours of continuous services provided. The continuous home
care rate is divided by 24 to yield an hourly rate. The number of hours
of continuous care provided during a continuous home care day is then
multiplied by the hourly rate to yield the continuous home care payment
for that day. A minimum of 8 hours of care must be furnished on a
particular day to qualify for the continuous home care rate.
(5) Subject to the limitations described in paragraph (f) of this
section, on any day on which the beneficiary is an inpatient in an
approved facility for inpatient care, the appropriate inpatient rate
(general or respite) is paid depending on the category of care
furnished. The inpatient rate (general or respite) is paid for the date
of admission and all subsequent inpatient days, except the day on which
the patient is discharged. For the day of discharge, the appropriate
home care rate is paid unless the patient dies as an inpatient. In the
case where the beneficiary is discharged deceased, the inpatient rate
(general or respite) is paid for the discharge day. Payment for
inpatient respite care is subject to the requirement that it may not be
provided consecutively for more than 5 days at a time. Payment for the
sixth and any subsequent day of respite care is made at the routine home
care rate.
(f) Payment for inpatient care is limited as follows: (1) The total
payment to the hospice for inpatient care (general or respite) is
subject to a limitation that total inpatient care days for Medicare
patients not exceed 20 percent of the total days for which these
patients had elected hospice care.
(2) At the end of a cap period, the intermediary calculates a
limitation on payment for inpatient care to ensure that Medicare payment
is not made for days of inpatient care in excess of 20 percent of the
total number of days of hospice care furnished to Medicare patients.
(3) If the number of days of inpatient care furnished to Medicare
patients is equal to or less than 20 percent of the total days of
hospice care to Medicare patients, no adjustment is necessary. Overall
payments to a hospice are subject to the cap amount specified in Sec.
418.309.
(4) If the number of days of inpatient care furnished to Medicare
patients exceeds 20 percent of the total days of hospice care to
Medicare patients, the total payment for inpatient care is determined in
accordance with the procedures specified in paragraph (f)(5) of this
section. That amount is compared to actual payments for inpatient care,
and any excess reimbursement must be refunded by the hospice. Overall
payments to the hospice are subject to the cap amount specified in Sec.
418.309.
(5) If a hospice exceeds the number of inpatient care days described
in paragraph (f)(4), the total payment for inpatient care is determined
as follows:
(i) Calculate the ratio of the maximum number of allowable inpatient
days to the actual number of inpatient care days furnished by the
hospice to Medicare patients.
(ii) Multiply this ratio by the total reimbursement for inpatient
care made by the intermediary.
(iii) Multiply the number of actual inpatient days in excess of the
limitation by the routine home care rate.
(iv) Add the amounts calculated in paragraphs (f)(5)(ii) and (iii)
of this section.
(g) Payment for routine home care, continuous home care, general
inpatient care and inpatient respite care is
[[Page 211]]
made on the basis of the geographic location where the services are
provided.
[48 FR 56026, Dec. 16, 1983, as amended at 56 FR 26919, June 12, 1991;
70 FR 45145, Aug. 4, 2005; 70 FR 70547, Nov. 22, 2005; 72 FR 50228, Aug.
31, 2007]
Sec. 418.304 Payment for physician and nurse practitioner services.
(a) The following services performed by hospice physicians and nurse
practitioners are included in the rates described in Sec. 418.302:
(1) General supervisory services of the medical director.
(2) Participation in the establishment of plans of care, supervision
of care and services, periodic review and updating of plans of care, and
establishment of governing policies by the physician member of the
interdisciplinary group.
(b) For services not described in paragraph (a) of this section, a
specified Medicare contractor pays the hospice an amount equivalent to
100 percent of the physician fee schedule for those physician services
furnished by hospice employees or under arrangements with the hospice.
Reimbursement for these physician services is included in the amount
subject to the hospice payment limit described in Sec. 418.309.
Services furnished voluntarily by physicians are not reimbursable.
(c) Services of the patient's attending physician, if he or she is
not an employee of the hospice or providing services under arrangements
with the hospice, are not considered hospice services and are not
included in the amount subject to the hospice payment limit described in
Sec. 418.309. These services are paid by the carrier under the
procedures in subpart B, part 414 of this chapter.
(d) Payment for hospice pre-election evaluation and counseling
services. The intermediary makes payment to the hospice for the services
established in Sec. 418.205. Payment for this service is set at an
amount established under the physician fee schedule, for an office or
other outpatient visit for evaluation and management associated with
presenting problems of moderate severity and requiring medical decision-
making of low complexity other than the portion of the amount
attributable to the practice expense component. Payment for this pre-
election service does not count towards the hospice cap amount.
(e)(1) Effective December 8, 2003, Medicare pays for attending
physician services provided by nurse practitioners to Medicare
beneficiaries who have elected the hospice benefit and who have selected
a nurse practitioner as their attending physician. This applies to nurse
practitioners without regard to whether they are hospice employees.
(2) Nurse practitioners may bill and receive payment for services
only if the--
(i) Nurse practitioner is the beneficiary's attending physician as
defined in Sec. 418.3;
(ii) Services are medically reasonable and necessary;
(iii) Services are performed by a physician in the absence of the
nurse practitioner; and
(iv) Services are not related to the certification of terminal
illness specified in Sec. 418.22.
(3) Payment for nurse practitioner services are made at 85 percent
of the physician fee schedule amount.
[48 FR 56026, Dec. 16, 1983, as amended at 69 FR 66426, Nov. 15, 2004;
70 FR 45145, Aug. 4, 2005; 70 FR 70547, Nov. 22, 2005]
Sec. 418.306 Determination of payment rates.
(a) Applicability. CMS establishes payment rates for each of the
categories of hospice care described in Sec. 418.302(b). The rates are
established using the methodology described in section 1814(i)(1)(C) of
the Act.
(b) Payment rates. The payment rates for routine home care and other
services included in hospice care are as follows:
(1) The following rates, which are 120 percent of the rates in
effect on September 30, 1989, are effective January 1, 1990 through
September 30, 1990 and October 21, 1990 through December 31, 1990:
Routine home care............................................. $75.80
Continuous home care:
Full rate for 24 hours...................................... 442.40
Hourly rate................................................. 18.43
Inpatient respite care........................................ 78.40
General inpatient care........................................ 337.20
[[Page 212]]
(2) Except for the period beginning October 21, 1990, through
December 31, 1990, the payment rates for routine home care and other
services included in hospice care for Federal fiscal years 1991, 1992,
and 1993 and those that begin on or after October 1, 1997, are the
payment rates in effect under this paragraph during the previous fiscal
year increased by the market basket percentage increase as defined in
section 1886(b)(3)(B)(iii) of the Act, otherwise applicable to
discharges occurring in the fiscal year. The payment rates for the
period beginning October 21, 1990, through December 31, 1990, are the
same as those shown in paragraph (b)(1) of this section.
(3) For Federal fiscal years 1994 through 2002, the payment rate is
the payment rate in effect during the previous fiscal year increased by
a factor equal to the market basket percentage increase minus--
(i) 2 percentage points in FY 1994;
(ii) 1.5 percentage points in FYs 1995 and 1996;
(iii) 0.5 percentage points in FY 1997; and
(iv) 1 percentage point in FY 1998 through FY 2002.
(4) For Federal fiscal year 2001, the payment rate is the payment
rate in effect during the previous fiscal year increased by a factor
equal to the market basket percentage increase plus 5 percentage points.
However, this payment rate is effective only for the period April 1,
2001 through September 30, 2001. For the period October 1, 2000 through
March 31, 2001, the payment rate is based upon the rule under paragraph
(b)(3)(iv) of this section. The payment rate in effect during the period
April 1, 2001 through September 30, 2001 is considered the payment rate
in effect during fiscal year 2001.
(5) The payment rate for hospice services furnished during fiscal
years 2001 and 2002 is increased by an additional 0.5 percent and 0.75
percent, respectively. This additional amount is not included in
updating the payment rate as described in paragraph (b)(3) of this
section.
(c) Adjustment for wage differences. CMS will issue annually, in the
Federal Register, a hospice wage index based on the most current
available CMS hospital wage data, including any changes to the
definitions of Metropolitan Statistical Areas. The payment rates
established by CMS are adjusted by the intermediary to reflect local
differences in wages according to the revised wage index.
(d) Federal Register notices. CMS publishes as a notice in the
Federal Register any proposal to change the methodology for determining
the payment rates.
[56 FR 26919, June 12, 1991, as amended at 59 FR 26960, May 25, 1994; 62
FR 42882, Aug. 8, 1997; 70 FR 70548, Nov. 22, 2005]
Sec. 418.307 Periodic interim payments.
Subject to the provisions of Sec. 413.64(h) of this chapter, a
hospice may elect to receive periodic interim payments (PIP) effective
with claims received on or after July 1, 1987. Payment is made biweekly
under the PIP method unless the hospice requests a longer fixed interval
(not to exceed one month) between payments. The biweekly interim payment
amount is based on the total estimated Medicare payments for the
reporting period (as described in Sec. Sec. 418.302-418.306). Each
payment is made 2 weeks after the end of a biweekly period of service as
described in Sec. 413.64(h)(5) of this chapter. Under certain
circumstances that are described in Sec. 413.64(g) of this chapter, a
hospice that is not receiving PIP may request an accelerated payment.
[59 FR 36713, July 19, 1994]
Sec. 418.308 Limitation on the amount of hospice payments.
(a) Except as specified in paragraph (b) of this section, the total
Medicare payment to a hospice for care furnished during a cap period is
limited by the hospice cap amount specified in Sec. 418.309.
(b) Until October 1, 1986, payment to a hospice that began operation
before January 1, 1975 is not limited by the amount of the hospice cap
specified in Sec. 418.309.
(c) The intermediary notifies the hospice of the determination of
program reimbursement at the end of the cap year in accordance with
procedures similar to those described in Sec. 405.1803 of this chapter.
[[Page 213]]
(d) Payments made to a hospice during a cap period that exceed the
cap amount are overpayments and must be refunded.
[48 FR 56026, Dec. 16, 1983; 48 FR 57282, Dec. 29, 1983]
Sec. 418.309 Hospice cap amount.
The hospice cap amount is calculated using the following procedures:
(a) The cap amount is $6,500 per year and is adjusted for inflation
or deflation for cap years that end after October 1, 1984, by using the
percentage change in the medical care expenditure category of the
Consumer Price Index (CPI) for urban consumers that is published by the
Bureau of Labor Statistics. This adjustment is made using the change in
the CPI from March 1984 to the fifth month of the cap year. The cap year
runs from November 1 of each year until October 31 of the following
year.
(b) Each hospice's cap amount is calculated by the intermediary by
multiplying the adjusted cap amount determined in paragraph (a) of this
section by the number of Medicare beneficiaries who elected to receive
hospice care from that hospice during the cap period. For purposes of
this calculation, the number of Medicare beneficiaries includes--
(1) Those Medicare beneficiaries who have not previously been
included in the calculation of any hospice cap and who have filed an
election to receive hospice care, in accordance with Sec. 418.24, from
the hospice during the period beginning on September 28 (35 days before
the beginning of the cap period) and ending on September 27 (35 days
before the end of the cap period).
(2) In the case in which a beneficiary has elected to receive care
from more than one hospice, each hospice includes in its number of
Medicare beneficiaries only that fraction which represents the portion
of a patient's total stay in all hospices that was spent in that
hospice. (The hospice can obtain this information by contacting the
intermediary.)
Sec. 418.310 Reporting and recordkeeping requirements.
Hospices must provide reports and keep records as the Secretary
determines necessary to administer the program.
Sec. 418.311 Administrative appeals.
A hospice that believes its payments have not been properly
determined in accordance with these regulations may request a review
from the intermediary or the Provider Reimbursement Review Board (PRRB)
if the amount in controversy is at least $1,000 or $10,000,
respectively. In such a case, the procedure in 42 CFR part 405, subpart
R, will be followed to the extent that it is applicable. The PRRB,
subject to review by the Secretary under Sec. 405.1874 of this chapter,
shall have the authority to determine the issues raised. The methods and
standards for the calculation of the payment rates by CMS are not
subject to appeal.
Subpart H_Coinsurance
Sec. 418.400 Individual liability for coinsurance for hospice care.
An individual who has filed an election for hospice care in
accordance with Sec. 418.24 is liable for the following coinsurance
payments. Hospices may charge individuals the applicable coinsurance
amounts.
(a) Drugs and biologicals. An individual is liable for a coinsurance
payment for each palliative drug and biological prescription furnished
by the hospice while the individual is not an inpatient. The amount of
coinsurance for each prescription approximates 5 percent of the cost of
the drug or biological to the hospice determined in accordance with the
drug copayment schedule established by the hospice, except that the
amount of coinsurance for each prescription may not exceed $5. The cost
of the drug or biological may not exceed what a prudent buyer would pay
in similar circumstances. The drug copayment schedule must be reviewed
for reasonableness and approved by the intermediary before it is used.
(b) Respite care. (1) The amount of coinsurance for each respite
care day is equal to 5 percent of the payment made by CMS for a respite
care day.
(2) The amount of the individual's coinsurance liability for respite
care during a hospice coinsurance period may
[[Page 214]]
not exceed the inpatient hospital deductible applicable for the year in
which the hospice coinsurance period began.
(3) The individual hospice coinsurance period--
(i) Begins on the first day an election filed in accordance with
Sec. 418.24 is in effect for the beneficiary; and
(ii) Ends with the close of the first period of 14 consecutive days
on each of which an election is not in effect for the beneficiary.
Sec. 418.402 Individual liability for services that are not considered hospice care.
Medicare payment to the hospice discharges an individual's liability
for payment for all services, other than the hospice coinsurance amounts
described in Sec. 418.400, that are considered covered hospice care (as
described in Sec. 418.202). The individual is liable for the Medicare
deductibles and coinsurance payments and for the difference between the
reasonable and actual charge on unassigned claims on other covered
services that are not considered hospice care. Examples of services not
considered hospice care include: Services furnished before or after a
hospice election period; services of the individual's attending
physician, if the attending physician is not an employee of or working
under an arrangement with the hospice; or Medicare services received for
the treatment of an illness or injury not related to the individual's
terminal condition.
Sec. 418.405 Effect of coinsurance liability on Medicare payment.
The Medicare payment rates established by CMS in accordance with
Sec. 418.306 are not reduced when the individual is liable for
coinsurance payments. Instead, when establishing the payment rates, CMS
offsets the estimated cost of services by an estimate of average
coinsurance amounts hospices collect.
[56 FR 26919, June 12, 1991]