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.

This provision establishes the organizational, administrative, and operational requirements for hospices, including governing body responsibilities and service delivery standards.

Condition of participation: Medical director.

This provision mandates the designation of a medical director and defines their responsibilities regarding patient care and terminal illness certification.

Condition of participation: Clinical records.

This provision outlines the requirements for maintaining, protecting, and retaining clinical records for hospice patients.

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

This provision sets standards for the management, administration, storage, and disposal of medications and the maintenance of durable medical equipment in hospice care.

Condition of participation: Short-term inpatient care.

This provision establishes requirements for hospice inpatient care, including symptom management, respite care, and the contractual arrangements required when hospice services are provided in a hospital or nursing facility.

Condition of participation: Hospices that provide inpatient care directly.

This provision establishes mandatory conditions of participation for hospice inpatient care, covering staffing, physical environment, safety, clinical services, and restraint and seclusion requirements.

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

This provision establishes the conditions of participation for hospices providing care to residents in nursing facilities or intermediate care facilities, including requirements for written agreements, professional management, care coordination, and staff training.

Condition of participation: Emergency preparedness.

The hospice must establish and maintain an emergency preparedness program, including a risk assessment, emergency plan, policies and procedures, communication plan, and training and testing program.

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.

Hospices must operate in compliance with all applicable laws and regulations, maintain required licensure, disclose ownership information, and adhere to laboratory testing standards.

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.

Hospice services must be reasonable and necessary for palliation, elected by the patient, and provided under a physician-reviewed plan of care.

Covered services.

This section lists the specific services covered under the hospice benefit, including nursing, medical social services, counseling, and therapy.

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.

This provision outlines the coinsurance liability for hospice patients regarding palliative drugs, biologicals, and respite care services.

Individual liability for services that are not considered hospice care.

This provision clarifies that Medicare payment to a hospice covers hospice-related services, while patients remain liable for non-hospice services and applicable deductibles.

Effect of coinsurance liability on Medicare payment.

This provision states that Medicare payment rates to hospices are not reduced by patient coinsurance, as CMS accounts for these estimates when setting rates.

Condition of participation: Patient's rights.

This provision mandates that hospices protect and promote patient rights, including notice of rights, advance directives, grievance procedures, and protection from abuse.

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

This provision requires hospices to conduct and document timely, patient-specific comprehensive assessments covering physical, psychosocial, emotional, and spiritual needs.

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

This provision requires hospices to maintain an interdisciplinary group to develop, review, and coordinate individualized written plans of care for each patient.

Condition of participation: Quality assessment and performance improvement.

Hospices must implement an ongoing, data-driven quality assessment and performance improvement program that monitors patient care, safety, and palliative outcomes.

Condition of participation: Infection control.

Hospices must maintain a coordinated, agency-wide infection control program that includes surveillance, prevention, and education for staff and patients.

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.

Hospices must provide core services, including nursing, medical social services, and counseling, directly by employees, with specific standards for each discipline.

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.

Hospices must ensure that non-core services are provided directly or under arrangement in accordance with current standards of practice.

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

Hospices must ensure that physical, occupational, and speech-language pathology services are available and provided according to 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.

This provision establishes the qualification, training, competency evaluation, supervision, and duty requirements for hospice aides and homemakers providing care to hospice patients.

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.