Section R414-14A-5 - Service Coverage(1) Hospice service coverage includes medically necessary services as outlined in Subsection R414-1-2(18).(2) Continuous home care is limited to alleviate or manage acute medical symptoms. (a) Extended stay residents of nursing facilities are not eligible for continuous home care days.(b) Continuous home care is covered only as required to maintain the terminally ill member at the member's place of residence.(c) The hospice agency shall maintain documentation to support the requirement that the service was medically necessary and complied with an established plan of care.(3) Medicaid covers hospice room and board in a nursing facility, ICF/ID, or a freestanding hospice inpatient facility and includes:(a) medication administration;(d) routine and therapeutic dietary services, including direct feeding assistance;(e) maintaining the cleanliness of the member's room;(f) assistance with activities of daily living (ADLs);(g) durable medical equipment;(h) medical supplies; and(i) prescribed therapies.(4) Other services unrelated to care associated with the terminal illness are covered under the Utah Medicaid State Plan nursing facility benefit.(5) If a member who resides in a nursing facility revokes one's hospice benefits, the hospice agency shall notify the facility of the revocation. The following notification requirements apply: (a) the notice must be in writing; and(b) the hospice agency must provide the notification to the facility on or before the revocation date.(6) A member may receive general inpatient care provided in a hospice inpatient unit, a hospital, or a nursing facility. General inpatient care days may not be used due to the breakdown of the primary caregiving living arrangements or the collapse of other sources of support for the member.(7) Any change in hospice agencies must adhere to the requirements of 42 CFR 418.30. The member or the member's legal representative shall file the change with both the hospice agency from which care has been received and with the newly designated hospice agency on or before the effective date.(8) A member or legal representative may voluntarily revoke the member's election of hospice benefits. The member or the member's representative must sign an acknowledgement that the member will forfeit hospice service coverage for any remaining days in the election period.(9) Medicaid does not separately cover modalities for palliative purposes as this is the responsibility of the hospice agency. For the duration of an election for hospice care services, an individual waives rights to Medicaid payments for the following services. (a) Hospice care provided by a hospice agency other than the hospice agency designated by the individual, unless provided under arrangements made by the designated hospice agency.(b) Services for illnesses or conditions unrelated to the member's terminal illness, as these services are covered ancillary to hospice benefits when provided by an appropriate provider or facility.(c) Any Medicaid services related to the treatment of the terminal condition for which hospice care was elected, or a related condition, or that are equivalent to hospice care except for services provided by: (i) the designated hospice agency;(ii) another hospice agency under arrangements made by the designated hospice agency; and(iii) the individual's attending physician if that physician is not an employee of the designated hospice agency or receiving compensation from the hospice agency for those services.(10) The following applies for concurrent care for members under 21 years of age. (a) For the duration of the election of hospice care, pediatric members may only receive hospice care that is: (i) provided by the designated hospice agency; or(ii) provided under arrangements made by the designated hospice agency.(b) Pediatric members who elect to receive hospice care services may also receive concurrent Medicaid State Plan services for the terminal illness and other related conditions.(c) Medicaid does not separately cover any modalities for palliative purposes as this is the responsibility of the hospice agency.(i) Hospice agencies that provide services outside of the hospice benefit shall report directly to Medicaid for coverage.(ii) Hospice agencies are not responsible for reimbursing other providers or facilities for life-prolonging services given to pediatric members.(d) Hospice agencies that perform pediatric care shall develop a training curriculum to ensure that the hospice's interdisciplinary team members, including volunteers, are adequately trained to provide hospice care services. Staff members and volunteers who provide pediatric hospice care services must receive training before providing hospice services and at least annually thereafter.(11) The training shall include the following pediatric-specific elements: (a) growth and development;(b) pediatric pain and symptom management;(c) loss, grief, and bereavement for pediatric families and the child;(d) communication with family, community, and interdisciplinary team;(e) psychosocial and spiritual care of children; and(f) coordination of care with the child's community.(g) Medicaid incorporates by reference standards for pediatric hospice care services set forth by the National Hospice and Palliative Care Organization, 2022.(12) The hospice agency is responsible for notifying Medicaid when a member is enrolled in hospice care, when a member is discharged from hospice care, when a member moves into a long-term care facility, ICF/ID, or freestanding inpatient hospice facility, or when there has been a change in hospice agencies.(13) If Medicare determines that a member is no longer eligible for Medicare coverage of hospice care services, then the member no longer qualifies for Medicaid coverage of hospice services. Subsequently, hospice agencies shall immediately notify Medicaid of the members change in eligibility upon learning of Medicare's determination. Medicaid coverage for hospice care services ends the day after Medicare notifies the hospice agency that the member is no longer eligible for hospice care.(14) Hospice agencies may not initiate the discharge of a member from hospice unless the member meets the circumstances outlined in 42 CFR 418.26.(15) Inpatient respite care follows special coverage requirements, which are outlined in 42 CFR 418.204(b)(2). (a) Medicaid does not cover inpatient respite care for members who reside in nursing facilities, ICF/IDs, or freestanding hospice inpatient units.(b) Medicaid may not provide consecutive coverage for inpatient respite care for more than five days at a time.Utah Admin. Code R414-14A-5
Amended by Utah State Bulletin Number 2022-20, effective 9/30/2022