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 licensed social worker (MSW).
• 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 patient’s condition and needs, and the 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.
• Respite care (continuous care of the individual to provide temporary relief to family members or friends from the duties of caring for the patient).
• Nutritional guidance by a registered dietitian.

The following limits apply to hospice care received in the individual’s home:

1. Visits of one or more hours in which skilled care is required by a registered nurse (RN), licensed practical nurse (LPN) or home health aide are limited to a combined total of 60 visits.
2. 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 an 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 inpatient hospice services):

1. Services for spiritual counseling or bereavement counseling.
2. Services to other family members.
3. Services provided by volunteers, household members, family, or friends.
4. Food, clothing, housing, or transportation.
5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps or support railings.
6. Homemaker or housekeeping services.
7. Financial or legal counseling services.
8. Custodial or maintenance care, except that benefits are provided for palliative care to a terminally ill patient subject to the limits stated.
9. Services or supplies not included in the written treatment plan or not specifically set forth as a covered benefit.
10. Social services or treatment for mental health.

If the individual’s life expectancy extends beyond six months, the individual’s family can apply to the Trust Office for a waiver of the six-month limitation. Limited extensions are granted by the Trust Office if it determines the treatment is medically necessary.

If, while receiving hospice care, an individual requires treatment for a condition unrelated to the terminal illness, normal plan benefits apply.