Hospice Care

Statutory basis.

This provision outlines the statutory basis for hospice care under the Social Security Act and the conditions for program participation.

Condition of Participation: Organization and administration of services.

The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

Condition of participation: Medical director.

The hospice must designate a physician to serve as medical director.

Condition of participation: Clinical records.

A clinical record containing past and current findings is maintained for each hospice patient.

Condition of participation: Drugs and biologicals, medical supplies, and durable medical equipment.

Medical supplies and appliances, as described in § 410.36 of this chapter;

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.

Condition of participation: Hospices that provide inpatient care directly.

A hospice that provides inpatient care directly in its own facility must demonstrate compliance with all of the following standards:

Condition of participation: Hospices that provide hospice care to residents of a SNF/NF or ICF/IID.

In addition to meeting the conditions of participation at § 418.10 through § 418.116, a hospice that provides hospice care to residents of a SNF/NF or ICF/IID must abide by the following additional standards.

Condition of participation: Emergency preparedness.

The hospice must comply with all applicable Federal, State, and local emergency preparedness requirements.

Condition of participation: Personnel qualifications.

This provision establishes the professional licensure, certification, and educational requirements for hospice personnel, as well as the mandate for criminal background checks for employees with direct patient contact or access to records.

Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.

The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients.

Scope of part.

This section outlines the statutory basis, scope, and structure of the hospice care regulations.

Eligibility requirements.

In order to be eligible to elect hospice care under Medicare, an individual must be—

Requirements for coverage.

To be covered, hospice services must meet the following requirements.

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.

Special coverage requirements.

This section details coverage for continuous nursing care during crises, respite care, and bereavement counseling.

Special requirements for hospice pre-election evaluation and counseling services.

This section specifies the requirements for physician-provided pre-election evaluation and counseling services for Medicare beneficiaries.

Duration of hospice care coverage—Election periods.

This section defines the election periods for hospice care coverage.

Certification of terminal illness.

This section mandates the timing, content, and documentation requirements for certifying a patient's terminal illness for hospice eligibility.

Election of hospice care.

This provision outlines the requirements for the hospice election statement, the addendum for non-covered items, the notice of election filing process, and the waiver of other Medicare benefits upon electing hospice care.

Admission to hospice care.

This provision outlines the requirements for hospice admission, including physician recommendation and the certification of terminal illness.

Discharge from hospice care.

This provision establishes the criteria and procedural requirements for discharging a patient from hospice care, including discharge for cause and discharge planning.

Revoking the election of hospice care.

This provision defines the process for a patient or representative to revoke their election of hospice care and the resulting impact on Medicare coverage.

Definitions.

For purposes of this part—

Change of the designated hospice.

This provision outlines the requirements for a patient to change their designated hospice provider once during an election period.

Basic rules.

This provision sets the fundamental rules for Medicare payment and reimbursement caps for hospice care services.

Payment procedures for hospice care.

This provision details the payment categories, rates, and procedures for hospice care, including home care and inpatient respite care.

Payment for physician, and nurse practitioner, and physician assistant services.

This provision outlines the payment methodology and conditions for physician, nurse practitioner, and physician assistant services provided to hospice patients.

Annual update of the payment rates and adjustment for area wage differences.

This provision establishes the methodology for annual hospice payment rate updates and adjustments based on local area wage indices.

Periodic interim payments.

Subject to the provisions of § 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.

Limitation on the amount of hospice payments.

This provision defines the aggregate cap on total Medicare payments to a hospice and the requirements for filing cap determination notices.

Hospice aggregate cap.

A hospice's aggregate cap is calculated by multiplying the adjusted cap amount (determined in paragraph (a) of this section) by the number of Medicare beneficiaries, as determined by one of two methodologies for determining the number of...

Reporting and recordkeeping requirements.

Hospices are required to maintain records and provide reports as determined necessary by the Secretary for program administration.

Administrative appeals.

This provision outlines the process for hospices to appeal payment determinations through the intermediary or the Provider Reimbursement Review Board.

Data submission requirements under the hospice quality reporting program.

This provision mandates the submission of quality data, including CAHPS survey data, and outlines the reconsideration and exemption processes for hospice quality reporting.

Individual liability for coinsurance for hospice care.

An individual who has filed an election for hospice care in accordance with § 418.24 is liable for the following coinsurance payments.

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 § 418.400, that are considered covered hospice care (as described in § 418.202).

Effect of coinsurance liability on Medicare payment.

The Medicare payment rates established by CMS in accordance with § 418.306 are not reduced when the individual is liable for coinsurance payments.

Condition of participation: Patient's rights.

The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights.

Condition of participation: Initial and comprehensive assessment of the patient.

The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care.

Condition of participation: Interdisciplinary group, care planning, and coordination of services.

The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient.

Condition of participation: Quality assessment and performance improvement.

The hospice must develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program.

Condition of participation: Infection control.

The hospice must maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases.

Condition of participation: Licensed professional services.

Licensed professionals in a hospice must be qualified, practice under hospice policies, and actively participate in care coordination and quality improvement.

Condition of participation: Core services.

A hospice must routinely provide substantially all core services directly by hospice employees.

Condition of participation: Nursing services—Waiver of requirement that substantially all nursing services be routinely provided directly by a hospice.

Hospices in non-urbanized areas may request a waiver from the requirement to provide nursing services directly if they demonstrate good faith recruitment efforts.

Condition of participation: Furnishing of non-core services.

A hospice must ensure that the services described in § 418.72 through § 418.78 are provided directly by the hospice or under arrangements made by the hospice as specified in § 418.100.

Condition of participation: Physical therapy, occupational therapy, and speech-language pathology.

Physical therapy services, occupational therapy services, and speech-language pathology services must be available, and when provided, offered in a manner consistent with accepted standards of practice.

Waiver of requirement—Physical therapy, occupational therapy, speech-language pathology, and dietary counseling.

Hospices in non-urbanized areas may request a waiver for providing certain therapy and dietary counseling services if they demonstrate good faith recruitment efforts.

Condition of participation: Hospice aide and homemaker services.

All hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section.

Conditions of participation—Volunteers.

Hospices must maintain documented volunteer training, defined roles, recruitment efforts, and ensure volunteer service hours meet a minimum threshold of total patient care hours.