Section 437.424 - Covered ServicesThe hospice provider must provide services for the palliation and management of the terminal illness and related conditions. All services must be performed by appropriately qualified personnel, but the nature of the service, rather than the qualifications of the person who provides it, determines the reimbursement category of the service, as defined in 130 CMR 437.424. The following services are covered hospice services.
(A)Nursing Services. The hospice must provide nursing care and services by or under the supervision of a nurse. Nursing services must ensure that the nursing needs of the member are met as identified in the member's initial assessment, comprehensive assessment, and any updated comprehensive assessments. The hospice provider is responsible for providing all routine nursing care that can be completed during a standard nursing visit, including the collection of vital signs and treatment of minor injuries or sores, and all such routine nursing care must be completed by the hospice nurse unless the member resides in a nursing facility or ICF/IID and provision of certain routine nursing care is appropriately coordinated with the nursing facility or ICF/IID in accordance with 42 CFR 418.112.(B)Medical Social Services. Medical social services must be provided by a qualified social worker under the direction of a physician. The social worker is responsible for analyzing and assessing social and emotional factors and the member's capacity to cope with them, helping the member and the member's family follow hospice recommendations, and assisting the member's family with personal and environmental difficulties and in using community resources.(C)Physician Services. In addition to palliation and management of terminal illness and related conditions, physicians employed by or under contract with the hospice provider, including the physician member of the hospice interdisciplinary team, must also meet the general medical needs of the members to the extent that these needs are not met by the member's attending physician. Physicians may bill MassHealth for services not related to the terminal illness according to MassHealth physician regulations at 130 CMR 433.000: Physician Services.(D)Counseling Services. The following counseling services must be available to the member and member's family or other persons caring for the member at home. (1)Bereavement Counseling. An organized plan of care for bereavement counseling must be developed by a qualified professional under the auspices of the hospice provider. This plan of care must reflect family needs, delineate the services to be provided, and specify the frequency of service delivery. Bereavement counseling is a required hospice service, but is not reimbursable.(2)Dietary Counseling. When needed, dietary counseling services must be provided by a qualified professional.(3)Spiritual Counseling. The hospice must:(a) Provide an assessment of the member's and family's spiritual needs.(b) Provide spiritual counseling to meet these needs in accordance with the member's and family's acceptance of this service, and in a manner consistent with the member and family beliefs and desires.(c) Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the member's spiritual needs(4)Additional Counseling. Additional counseling may be provided by other members of the hospice interdisciplinary team as well as by other qualified professionals as determined by the hospice provider.(E)Physical, Occupational, and Speech/Language Therapy. The hospice must ensure that physical, occupational, and speech/language therapy services are provided by qualified personnel and in accordance with accepted standards of practice.(F)Hospice Aide/Homemaker Services. The hospice provider must arrange and supply hospice aide and homemaker services that are ordered by the hospice interdisciplinary team, and are provided in accordance with 42 CFR 418.76. Hospice aide and homemaker services may include the provision of personal care and household services. A registered nurse must visit the member's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide to ensure that services ordered by the hospice interdisciplinary team meet the member's needs. The hospice aide does not have to be present during this visit.(G)Drugs and Durable Medical Equipment and Medical Supplies. The hospice provider must provide all drugs, durable medical equipment, and medical supplies related to the palliation and management of the members terminal illness and related conditions, as identified in the member's plan of care while the member is under hospice care. The hospice must also comply with 42 CFR 418.106. Any person permitted by state law to do so may administer drugs. Pharmacy and durable medical equipment providers may bill MassHealth separately only for those services not related to the member's terminal illness, according to the MassHealth pharmacy regulations at 130 CMR 406.000: Pharmacy Services and durable medical equipment regulations at 130 CMR 409.000: Durable Medical Equipment Systems, as applicable.(H)Short-term Inpatient Care.(1)Facilities. Short-term general inpatient care for pain control and symptom management and inpatient respite care must be provided in a facility that meets the criteria specified in 42 CFR 418.108.(2)Limitations. During the 12-month period beginning October 1st of each year and ending September 30th of the following year, the aggregate number of inpatient days (for both general inpatient care and inpatient respite care) may not exceed 20% of the aggregate number of days of hospice services provided to all MassHealth members during that same period.(I)Other Covered Items and Services. Other covered items and services include those items and services that are specified in the plan of care and for which MassHealth payment may otherwise be made.Amended by Mass Register Issue 1485, eff. 1/1/2023.