N.J. Admin. Code § 10:54-5.29

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:54-5.29 - Hospice services; general

(a) The New Jersey Medicaid/NJ FamilyCare program provides hospice services under N.J.A.C. 10:60-2.15(a)7 and 3.16(a)7, the AIDS Community Care Alternatives Program (ACCAP) and 10:53A-3.4, hospice services to other Medicaid beneficiaries.

(b) Hospice care under the ACCAP program shall be approved by the attending physician and available to ACCAP beneficiaries on a 24-hour a day basis, as needed, in accordance with the beneficiary's plan of care, by a Medicaid/NJ FamilyCare approved, Medicare certified hospice agency. Reimbursement shall be at an established fee paid on a per diem basis to the hospice. Hospice services under ACCAP include only:

1. Services within the home;

2. Skilled nursing visits;

3. Hospice agency medical director services;

4. Medical social service visits;

5. Occupational therapy, physical therapy and speech-language pathology services;

6. Intravenous therapy;

7. Durable medical equipment;

8. Medication related to symptom control of the terminal illness; and

9. Case management as part of the hospice service.

(c) The requirements of this rule apply to hospice services available under N.J.A.C. 10:53A and shall not apply to those services under ACCAP. The attending physician shall certify:

1. The applicant's terminal illness; and

2. That hospice services are reasonable and necessary for the palliation and management of the terminal illness or related conditions.

(d) The attending physician, who must be a doctor of medicine (M.D.) or osteopathy (D.O.), must be the physician identified by the Medicaid/NJ FamilyCare applicant at the time the applicant elects to receive hospice services as the primary physician in the determination and the delivery of the applicant's medical care.

(e) The written "Physician Certification/Recertification for Hospice Benefits Form, FD-385 (6/92)" for the first period of hospice coverage (see N.J.A.C. 10:53A) shall be obtained by the hospice from the attending physician within two calendar days after hospice care is initiated.

1. If the hospice does not obtain written certification from the attending physician within two days after the initiation of hospice care, a verbal certification may be obtained within these two days and a written certification no later than eight calendar days after care is initiated. If these requirements are not met, no payment can be made for any days prior to the certification.

2. The signing of the written form shall be done by the hospice Medical Director, or physician of the interdisciplinary team and the attending physician (if the applicant has an attending physician), and shall include the statement that the applicant's medical prognosis is such that the life expectancy is six months or less.

(f) If the hospice beneficiary revokes hospice benefit package and then reenters the hospice in any subsequent period, the hospice shall obtain, no later than seven calendar days after the beginning of that period, a written "Physician Certification/Recertification for Hospice Benefits Form, FD-385 (6/92)" prepared by the Medical Director of the hospice or the physician member of the hospice's interdisciplinary group.

(g) For subsequent recertifications, a written recertification shall be obtained no later than two business days after the period begins (after the first 90-day benefit period, after the next 90-day benefit period, and after the third 30-day period). The Medical Director of the hospice or physician member of the interdisciplinary team shall recertify that the individual is terminally ill and that hospice services are reasonable and necessary for the palliation and management of the terminal illness or related condition, and, in addition, recertify the necessity of the continuing need for hospice services.

(h) In addition, the individual's attending physician is required to recertify the terminal illness for the fourth, and unlimited, benefit period, as described below:

1. An additional "Physician Certification/Recertification for Hospice Benefits Form, FD-385 (6/92)" shall be obtained by the hospice from the attending physician prior to the fourth unlimited period, but no later than two days after the period begins.

(i) Individuals requesting or initiating hospice eligibility should be referred to a Medicaid approved hospice to complete the hospice medical eligibility requirements for hospice services.

(j) For those cases in which the disability determination for Medicaid eligibility is within the jurisdiction of the Disability Review Section, Division of Medical Assistance and Health Services, the determination of disability for the first six months of hospice services will be based solely on a physician's certification of terminal illness. (See also 10:71-3.11 through 10:71-3.13.)

(k) To ensure the continuity of hospice services after six months, the agency responsible for eligibility determination (for example, the County Board of Social Services (CBOSS)) shall inform the Disability Review Section of the beneficiary's eligibility for hospice services based upon the physician's certification of terminal illness and the determination of financial eligibility.

(l) After the initial six-month period, if it appears that a beneficiary will require, and elects to continue to receive, hospice services, the Disability Review Section of the Division shall be provided with, in addition to the Hospice Benefits Form (FD-385), medical documentation to validate the disability status, based on terminal illness as part of the medical recertification. The required additional documentation consists of the following:

1. A statement from the attending physician of the diagnosis(es), prognosis and the stage of illness;

2. Copies of laboratory test results, biopsy and/or pathology reports, Magnetic Resonance Imaging (MRI) and Computerized Axial Tomography (CAT) results; and

3. Copies of any other objective medical documentation which supports the diagnosis(es).

(m) Individuals who are over 65 years of age, or receiving Medicare, or receiving Social Security Disability Insurance Benefits under Title II or Supplemental Security Income (SSI) under Title XVI, or who are on Aid to Families with Dependent Children (AFDC) are not required to be evaluated by the Medicaid Disability Review Section for hospice services.

(n) The Disability Review Section will identify and track individuals who are required to be evaluated for continuing disability and will contact the provider to initiate the enhanced recertification process.

(o) The New Jersey Medicaid/NJ FamilyCare program shall reimburse the hospice provider for direct patient care services furnished to Medicaid/NJ FamilyCare hospice beneficiaries by a hospice physician employee, and for physician services furnished under arrangements made by the hospice, unless the physician services were provided on a volunteer basis.

(p) The administrative and general supervisory activities performed by physicians who are employees of or working under arrangements with the hospice provider, would generally be performed by the medical director and/or the physician member of the hospice interdisciplinary group.

1. Interdisciplinary group activities include participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care, and the establishment of governing policies. These costs are included in the per diem rate, and shall not be billed separately.

(q) Physician services furnished on a volunteer basis shall be excluded from Medicaid/NJ FamilyCare reimbursement. The hospice may bill for services that are not provided on a volunteer basis, but the physician shall treat Medicaid/NJ FamilyCare beneficiaries on the same basis as other individuals in the hospice. For example, a physician shall not designate all physician services rendered to non-Medicaid/NJ FamilyCare individuals as volunteered and at the same time seek payment from the hospice for all physician services rendered to Medicaid/NJ FamilyCare hospice beneficiaries.

(r) The hospice shall directly bill the fiscal agent of the New Jersey Medicaid/NJ FamilyCare program on behalf of the physician, only for other direct personal care physician services (beyond interdisciplinary group activities, administration and/or supervision) furnished by hospice physician employees and for the same physician services under arrangements made by the hospice provider (unless the services are provided on a volunteer basis).

(s) In determining which hospice services are furnished on a volunteer basis and which services are not, a physician shall treat the Medicaid/NJ FamilyCare hospice beneficiary on the same basis as other individuals in the hospice.

(t) The hospice provider shall reimburse the physician for physician services described in (d) above. In this instance, the costs of the direct patient care of the attending physician, as an employee of the hospice agency, shall be billed on the CMS 1500 claim form by the hospice to the fiscal agent of the New Jersey Medicaid/NJ FamilyCare program.

(u) The attending physician, who is not an employee, or the hospice on behalf of the employee physician, shall bill only for direct personal care services and not for other cost of laboratory or X-rays, which are to be included in the hospice per diem rate.

(v) The costs of the attending physician services shall not be counted in determining whether the "hospice cap" has been exceeded, as these services are not part of the hospice services.

(w) The New Jersey Medicaid/NJ FamilyCare program shall reimburse for attending physician services and other specialty physician services (including physician consultation services) separate from the hospice per diem rates, under the following conditions:

1. The hospice shall notify the New Jersey Medicaid/NJ FamilyCare program by stating in the plan of care, the election of and the name of the physician who has been designated the attending physician, whenever the attending physician is not a hospice employee;

2. The attending physician shall not be a volunteer and/or shall not be part of the administrative staff or medical director of the hospice;

3. The attending physician shall provide direct patient care as an employee of the hospice or under arrangements with the hospice;

4. The attending physician services related or unrelated to the individual's terminal illness; and

5. Under the circumstances listed in (w)1 through 4 above, the attending physician or physician consultant shall submit the CMS 1500 claim form directly to the fiscal agent of the New Jersey Medicaid/NJ FamilyCare program and not through billing procedures of the hospice provider.

N.J. Admin. Code § 10:54-5.29

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
Substituted references to beneficiary and beneficiaries for references to recipient and recipients throughout the section.
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
Inserted "/NJ FamilyCare" throughout; in (a), deleted "N.J.A.C. 10:60-" preceding "3.16(a)7" and a comma following "(ACCAP)"; in (q), substituted "that" for "which"; in (t) and (w)5, substituted "CMS" for "HCFA"; in (w)1 through (w)3, deleted "and" from the end; in (w)4, substituted "; and" for a period at the end; and in (w)5, deleted a comma following "program".