N.J. Admin. Code § 10:53A-3.4
Current through Register Vol. 56, No. 21, November 4, 2024
Section 10:53A-3.4 - Covered hospice services(a) The amount, character, and scope of New Jersey Medicaid/NJ FamilyCare FFS hospice services shall be the same for all hospice beneficiaries and shall not be less than the hospice services provided under Medicare (Title XVIII) (Section 1861(dd) et seq. of the Social Security Act, codified as 42 U.S.C. Section 1395x(dd)1).(b) The Division reimburses for covered hospice services that are reasonable and necessary for the palliation and management of the terminal illness, and which are provided to a hospice beneficiary consistent with the beneficiary's individualized plan of care. 1. Required hospice services which shall be available to the hospice beneficiary include nursing care, medical social services, supervisory physician services, counseling services, durable medical equipment and supplies including drugs and biologicals, homemaker/home health aide services, physical therapy, occupational therapy and speech-language pathology services. i. The following services are considered "core" hospice services: nursing care, medical social services, physician services and counseling services. (1) A hospice provider shall ensure that substantially all core services are routinely provided directly by hospice employees.(2) A hospice may use contracted staff, if necessary, to supplement hospice employees in order to meet the needs of hospice beneficiaries during periods of peak patient loads or under extraordinary circumstances or to obtain physician specialty services.(3) If contracted staff is used, the hospice shall maintain professional, financial and administrative responsibility for the services and shall assure the qualifications of the staff and that services meet all requirements under each level of care.2. Effective on August 4, 2003, any other item or service which is specified in the patient's plan of care and for which payment may otherwise be made under Medicaid shall be a covered service under the Medicaid/NJ FamilyCare hospice benefit. For example, a hospice determines that a patient's condition has worsened and has become medically unstable and that an inpatient stay will be necessary for proper palliation and management of the condition. The hospice adds this inpatient stay to the plan of care and decides that, due to the patient's fragile condition, the patient will need to be transported to the hospital by ambulance. In this case, the ambulance service becomes a covered hospice service.(c) Covered hospice services are reimbursed at predetermined, prospective, inclusive rates corresponding to one of four levels of care. Two of the levels of care are reimbursed for services provided in the home: Routine Home Care and Continuous Home Care; and two levels of care are reimbursed for services provided on an inpatient basis: Inpatient Respite Care and General Inpatient Care in either a hospital or nursing facility (see also, 10:53A-4.1) . The provisions at (c)1 through 4 below apply to the levels of care provided by the hospice. 1. The routine home care rate is reimbursed if less skill than professional registered nursing, or licensed practical nursing, or less intensity than continuous home care is needed to enable the person to remain at home.i. The routine home care rate includes the following services: routine nursing services, social work, counseling services, durable medical equipment, supplies, drugs, home health aide/homemakers, physical therapy, occupational therapy, and speech-language pathology services. The routine home care rate includes respite care delivered in the home that is not predominately nursing care.ii. The routine home care rate is reimbursed when the beneficiary is not receiving continuous home care, regardless of the volume and intensity of routine home care services.2. The continuous home care rate is reimbursed only during a period of medical crisis to maintain the beneficiary at home where most of care is skilled nursing care on a continuous basis to achieve palliation or management of the beneficiary's acute medical symptoms and only as necessary to maintain the beneficiary at home. i. A minimum of eight hours of nursing care must be provided during a 24-hour day which begins and ends at midnight before the Continuous Home Care rate can be paid. The nursing care need not be sequential, that is, four hours may be provided in the morning and four hours in the evening of the same day.ii. The nursing care must be provided either by a registered professional nurse, or a licensed practical nurse under the supervision of a registered professional nurse. More than half (four hours or more) of the period of care must be nursing care provided by licensed nurses.iii. The Continuous Home Care rate includes homemaker/home health aide services which may be provided to supplement the nursing care, but not to substitute for the minimal amount of nursing care provided by the licensed nurses.3. Inpatient respite care is short-term, occasional, inpatient care provided to the beneficiary in a hospital or nursing facility only when necessary to relieve the family members or other persons caring for the beneficiary at home. i. The inpatient respite care rate is not reimbursed for more than five consecutive days.ii. Inpatient respite care is provided by a hospice to a Medicaid hospice beneficiary in either a hospital or a nursing facility. The inpatient respite care rate or the payment of room and board services under hospice is not provided when a beneficiary is considered a nursing facility patient and not a hospice patient.4. The general inpatient care rate is reimbursed when provided in a hospital or nursing facility during periods of acute medical crisis, for palliative care, for pain control, or management of acute and severe clinical problems which cannot be managed in another setting.5. Concerning the limitation on the aggregate payments to hospice providers for inpatient respite care and general inpatient care, see 10:53A-4.3.(d) Specific services provided by a hospice within each level of care related to the terminal illness and paid under the per diem rate schedule, are listed as follows: 1. Nursing care provided by or under the supervision of a registered professional nurse;2. Physical therapy, occupational therapy, and speech-language pathology provided by a qualified therapist for the purpose of symptom control or to enable the beneficiary to maintain activities of daily living and basic functional skills;3. Medicaid social services provided by a social worker who has met the Medicare certification requirements for education (See 42 U.S.C. § 1395x) and is working under the direction of a physician and with the interdisciplinary team;4. Homemaker/home health aide services shall be provided by a homemaker/home health aide. i. Homemaker/home health aide services may be provided on a 24-hour, continuous basis but only during periods of a beneficiary's crisis, not a family crisis, and only as necessary to maintain the terminally ill beneficiary at home;ii. A registered professional nurse shall visit the home of the hospice beneficiary at least every two weeks when homemaker/home health aide services are provided for the purpose of assessing the homemaker/home health aide services and provide education and supervision to the aide, as needed;5. Durable medical equipment and supplies included in the plan of care, as well as self-help and personal comfort items which are reasonable and necessary for palliation and management of the beneficiary's terminal illness;6. Drugs and biologicals included in the plan of care primarily for the relief of pain and symptom control for a beneficiary's terminal illness; and7. Counseling, provided with respect to care of the terminally ill beneficiary, for family members or other persons caring for the beneficiary at home and provided by members of the interdisciplinary group, as well as by other qualified professionals as determined by the hospice provider.i. Counseling, including dietary counseling, shall be provided both for the purpose of training the beneficiary's family or other caregiver to provide care, and for the purpose of helping the beneficiary and those caring for him or her to adjust to the nature of the beneficiary's illness.ii. Bereavement counseling consists of counseling services provided to the beneficiary's family after the beneficiary's death under the supervision of a qualified professional. Bereavement counseling is a required inclusive component of hospice service and is not separately reimbursed by Medicaid/NJ FamilyCare. (1) The plan of care shall clearly delineate the type of counseling services to be provided and the frequency of the delivery of the service which shall be offered up to one year following the death of the beneficiary.iii. Dietary counseling, when necessary, provided by a qualified professional dietitian or dietary consultant.iv. Spiritual counseling including notice to the beneficiary as to the availability of appropriate clergy.(e) Room and board services identical to those provided to non-hospice Medicaid/NJ FamilyCare FFS beneficiaries shall be provided for hospice beneficiaries residing in a nursing facility. The beneficiary eligible for hospice services who is residing in a Medicaid/NJ FamilyCare FFS participating nursing facility is considered a hospice beneficiary not a patient of a nursing facility. 1. Room and board services include the performance of personal care services, assistance in activities of daily living, provision of patient social activities, the administration of medications, the maintenance of the cleanliness of a resident's room, and supervision and assistance in the use of durable equipment and prescribed therapies.2. The Pre-admission Screening (PAS) rules do not apply to a hospice patient admitted directly to a nursing facility or changed from nursing facility care to hospice care. This individual would be considered a hospice patient not an NF patient. If the hospice patient revokes the hospice benefits and returns to that NF's care or the care of another NF, the PAS rules apply which are in N.J.A.C. 10:63, Long Term Care Services.(f) Physician services for administration, interdisciplinary group activities, and general supervisory activities of the medical director, his or her designated representative, or other physician employees of the hospice provider, or those working under arrangements with the hospice, are considered "core services" and are included in the hospice per diem rate. These services shall not be billed separately to the fiscal agent. 1. The cost of physician services for direct personal care shall be covered as a separate service only for physician employees of the hospice who do not volunteer for these services. In such instances, the physician may receive separate reimbursement above the hospice per diem rate when physician services are billed by this employee. The hospice shall not bill on behalf of the physician for these direct personal care services. For the procedures for the reimbursement of these services, see 10:53A-4.2.(g) Regarding other covered services, some Medicaid/NJ FamilyCare FFS services which are not duplicative of hospice services may be covered by Medicaid/NJ FamilyCare FFS for the hospice beneficiary. These services include optometric and optical services, prosthetic and orthotic services, medical day care services, and personal care assistant services. These services must be approved by the interdisciplinary team, be consistent with the plan of care and be determined to be medically necessary. 1. The personal care assistant (PCA) services shall be provided to a hospice beneficiary by Medicaid/NJ FamilyCare FFS approved PCA providers. (See 10:60-1.7, 1.8 and 1.9, concerning Home Care Services). Personal care assistant services shall be included in the plan of care, and must not be duplicate services covered and reimbursed under the hospice per diem.2. Personal care assistant services for hospice beneficiaries shall be used only to replace the live-in primary adult caregiver as defined in 10:60-1.2, and provided under the limitations of 10:60-1.9.N.J. Admin. Code § 10:53A-3.4
Amended by R.1994 d.508, effective 10/17/1994.
See: 26 New Jersey Register 1283(a), 26 New Jersey Register 4185(a).
Amended by R.1997 d.479, effective 11/17/1997.
See: 29 New Jersey Register 3441(a), 29 New Jersey Register 4853(a).
Amended by R.2003 d.320, effective 8/4/2003.
See: 34 New Jersey Register 2899(a), 35 New Jersey Register 3568(a).
Rewrote the section.