Hospice
Care – 100%
Hospice
care refers to palliative care (medical relief of pain and other symptoms) for
individuals who have been diagnosed as terminally ill and whose life expectancy
has been determined to be six months or less.
A “hospice
program” is defined as a public agency or a private organization that is
primarily engaged in providing the care and services described below and that
makes these services available as needed, on a 24-hour basis. The hospice
program provides care and services in individuals’ homes and on a
short-term inpatient basis. The hospice program can either be a
Medicare-certified hospice agency or certified as a hospice care agency by the
Washington State Department of Social and Health Services or the equivalent
department of another state. A provider that is certified for Medicare
participation as a hospital, skilled nursing facility, or home health agency may
be certified as a hospice.
Hospice
care must be preauthorized with the Trust
Office and the
physician and the hospice agency must submit a written treatment plan to the
Trust Office which specifically describes the hospice care services and supplies
to be provided. At least once every two months, the physician must review the
plan and certify that the individual’s condition and treatment continue to
meet the hospice care criteria. Nurse practitioners may not independently
establish or update the plan of care, but they may review the plan of care as
part of the hospice team.
Benefits are provided for the
services and supplies of an approved hospice agency for a maximum of six months
as follows:
Covered
Charges For Services In the Individual’s Home
Home hospice care services
are covered if the individual is ill enough for hospitalization. In addition,
the individual must be “homebound” meaning the individual cannot
leave the home without a considerable and taxing effort and is unable to use
public transportation without the assistance of another.
Benefits are limited to the
following services which must be provided by employees of, and billed by, an
approved hospice:
- Physician
services.
- Nursing
services by a registered nurse (RN) or licensed practical nurse
(LPN).
- Physical
therapy by a physical therapist.
- Speech
therapy by a speech therapist.
- Occupational
therapy by an occupational therapist.
- Respiratory
therapy provided by a respiratory therapist.
- Medical
social services provided by a person with a master’s degree in social work
(MSW) under the direction of a physician.
- Home
health aide services by an aide who is under the supervision of a registered
nurse, are limited to the following: part-time or intermittent care including
ambulation and exercise, personal care essential to achieve the medically
desired result, assistance with medications, the reporting of changes in the
individual’s condition and needs, and completion of appropriate
records.
- Medical
supplies dispensed by the hospice that would have been provided on an inpatient
basis.
- Drugs
and medicines dispensed by or through the hospice agency, that are legally
obtainable only with a physician’s written prescription or provided on an
inpatient basis but only such drugs and medicines which are reasonable and
necessary for palliation and management of terminal illness.
- Respite
care (continuous care of the individual to provide temporary relief to family
members or friends from the duties of caring for the individual).
- Nutritional
guidance by a registered dietitian.
The
following limits apply to hospice care received in the individual’s
home:
- Visits
of one or more hours in which care is required by a registered nurse (RN),
licensed practical nurse (LPN), home health aide, master’s in social work
(MSW), or a physical, speech, occupational and respiratory therapist are limited
to a combined total of 60 visits.
- Respite
care in which no skilled care is required is limited to a combined total of 120
hours per three-month period.
Covered
Charges For Inpatient Hospice Services
When the individual is
confined as an inpatient in an approved hospice facility, the same benefits that
are available in the individual’s home are available to the individual on
an inpatient basis. These services must be provided by employees of, and billed
by, the approved hospice agency. This inpatient hospice benefit is
limited
to 14 days during the six-month benefit
period.
Benefits are
not
provided for (in the individual’s
home or as an inpatient hospice service):
- Services
for spiritual counseling or bereavement counseling.
- Services
to other family members.
- Services
provided by volunteers, household members, family, or friends.
- Food,
clothing, housing, or transportation.
- Supportive
environmental services or equipment such as, but not limited to, wheelchair
ramps or support railings.
- Homemaker
or housekeeping services.
- Financial
or legal counseling services.
- Custodial
or maintenance care, except that benefits are provided for palliative care to a
terminally ill individual subject to the limits stated.
- Services
or supplies not included in the written treatment plan or not specifically set
forth as a covered benefit.
- Social
services or treatment for mental health.
- Private
duty
nursing.
If,
while receiving hospice care, an individual requires treatment for a condition
not related to the terminal illness, normal plan benefits apply.
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