date approved: integrated healthcare services … community health plan (pchp) ... mc/n007 skilled...

Department of Origin: Integrated Healthcare Services

Approved by: Chief Medical Officer

Date Approved: 07/19/17

Department(s) Affected: Integrated Healthcare Services

Effective Date: 07/24/17

Medical Policy Document: Hospice Care

Replaces Effective Policy Dated: 03/16/16

Reference #: MP/H007 Page: 1 of 5

PRODUCT APPLICATION:

PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Insurance Company (PIC) Individual PreferredOne Insurance Company (PIC) Large Group PreferredOne Insurance Company (PIC) Small Group

Please refer to the member’s benefit document for specific information. To the extent there is any inconsistency between this policy and the terms of the member’s benefit plan or certificate of coverage, the terms of the member’s benefit plan document will govern. Benefits must be available for health care services. Health care services must be ordered by a physician, physician assistant, or nurse practitioner. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. PURPOSE: The intent of this policy is to provide coverage guidelines for hospice services. POLICY: PreferredOne covers hospice services for terminally ill patients in a hospice program. Members must meet the eligibility requirements of the program and elect to receive services through the hospice program. The services will be provided in the member’s home, with inpatient care available when medically necessary as described below. Hospice services are in lieu of curative or restorative treatment. A member may withdraw from the home hospice program at any time GUIDELINES: Must satisfy both of the following: I and II I. Member Requirements – one of the following: A or B A-C

A. Initial certification request (first 90-day period) – must satisfy both of the following: 1 and 2

1. Presence of terminal illness with a life expectancy of 6 months or less, as certified by a physician.

2. Chosen a palliative treatment focus, ie, emphasizing comfort and supportive services rather than curative or tumor-directed treatment

B. Recertification request (second 90-day period and subsequent 60 day periods) - there is a persistent decline

in clinical status from baseline in one or more of the domains found on Attachment A

C. Discharge – must satisfy any of the following: 1-4 1. Member is no longer considered terminally ill; or 2. Focus of care directed towards curative treatment for the terminal illness; or









3. Member or healthcare agent elects to discontinue participation of the member in the hospice program;

or 4. Member expires.

[Note: bereavement coverage could continue after member expires]

II. Covered Services A. Hospice must be a covered benefit.

B. Services are provided by a multidisciplinary team from a certified or accredited hospice agency.

C. Must be in accordance with an approved hospice plan of care, which is regularly reviewed based on a

comprehensive, interdisciplinary assessment of the member’s and family’s values, preferences, goals, and needs.

D. Part-time (up to two hours of service per calendar day) care in the member’s home by an interdisciplinary

hospice team (which may include a physician, nurse, social worker, and/or spiritual counselor), and home health aide services.

E. One or more periods of continuous care provided in the member’s home or in a setting that provides day care for pain or symptom management, when medically necessary.

F. Medically necessary inpatient services for acute symptom management related to the terminal condition,

eg, pain control. [Note: Must have a skilled need for coverage of room and board. Room and board for custodial/ maintenance care is not covered, except for respite (see G. below)]

G. Respite care for caregivers in the member’s home or in an appropriate setting – all of the following: 1-3

1. To give the member’s primary caregivers (ie, family, friends) rest and/or relief when necessary in order to maintain a terminally ill member at home; and

2. Respite care is limited by calendar days per episode. [Note: Check COC or SPD for calendar day limit]

3. The period of respite care and continuous care combined is limited while enrolled in the hospice

program. [Note: Check COC or SPD for combined respite and continuous care calendar day limit]

H. Medically necessary medications for pain and symptom management. I. Hospital beds and other durable medical equipment when medically necessary.

EXCLUSIONS: Either of the following: I or II

I. Coverage for services provided by the member’s family or a person that shares their legal residence. II. Respite care except as specifically describe above.









DEFINITIONS: Continuous Care: Two to twelve hours of service per calendar day provided by a registered nurse, licensed practical nurse, or home health aide, during a period of crisis in order to maintain a terminally ill member at home. Home: A place the member makes his or her residence. This may include a licensed residential care facility where skilled services are not included. Medically Necessary: Any health care service that PCHP, PIC, or the applicable PAS Plan Administrator in its discretion and on a case by case basis, determines are appropriate and necessary in terms of type, frequency, level, setting, and duration for the diagnosis or condition; and the care must be consistent with the medical standards and generally accepted practice parameters of the hospice medical community.









FOR INTERNAL USE ONLY COVERAGE: Prior Authorization: Yes – initial certification authorize one 90-day period, first recertification, allow an additional 90 day period; subsequent recertifications every 60-days, thereafter Coverage is subject to the member’s contract benefits. RELATED CRITERIA/POLICIES: Integrated Healthcare Services Process Manual: UR015 Use of Medical Policy and Criteria Integrated Healthcare Services Process Manual: UR020 Hospice Review Medical Policy: MP/C009 Coverage Determination Guidelines Medical Policy: MP/D004 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Medical Criteria: MC/N007 Skilled Intermittent Home Health Care Medical Criteria: MC/N008 Skilled Private Duty/Extended Hours Home Health Care REFERENCES: 1. Center to Advance Palliative Care (CAPC). A National Framework and Preferred Practices for Palliative and

Hospice Care Quality: A National Quality Forum (NQF) Consensus Report. Retrieved from http://www.qualityforum.org/Publications/2006/12/A_National_Framework_and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx

2. Choosing Wisely. American Academy of Hospice and Palliative Medicine, Five Things Physicians and Patients Should Question. American Board of Internal Medicine Foundation. 2013. Retrieved from http://www.choosingwisely.org/societies/american-academy-of-hospice-and-palliative-medicine/

3. McCusker M, Ceronsky L, Crone C, Epstein H, Greene B, Halvorson J, Kephart K, Mallen E, Nosan B, Rohr M, Rosenberg E, Ruff R, Schlecht K, Setterlund L. Institute for Clinical Systems Improvements. Palliative Care for Adults. Updated November 2013. Retrieved from https://www.icsi.org/_asset/k056ab/PalliativeCare.pdf

4. Agency for Healthcare Research and Quality (AHRQ). Improving Health Care and Palliative Care for Advanced and Serious Illness. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report/Technology Assessment Number 208. 2012. Retrieved from http://effectivehealthcare.ahrq.gov/ehc/products/325/1304/EvidenceReport208_CQGPalliativeCare_ExecutiveSummary_20121024.pdf

5. National Voluntary Consensus Standards: Palliative Care and End-of-Life Care - A Consensus Report. April 2012. http://www.qualityforum.org/Publications/2012/04/Palliative_Care_and_End-of-Life_Care%e2%80%94A_Consensus_Report.aspx

DOCUMENT HISTORY:

Created Date: 01/08/13 Reviewed Date: 01/08/13, 01/08/14, 12/30/14, 02/29/16, 02/28/17 Revised Date: 01/08/14, 05/11/15, 03/16/16, 07/19/17

http://www.qualityforum.org/Publications/2006/12/A_National_Framework_and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx

http://www.qualityforum.org/Publications/2006/12/A_National_Framework_and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx

http://www.choosingwisely.org/societies/american-academy-of-hospice-and-palliative-medicine/

https://www.icsi.org/_asset/k056ab/PalliativeCare.pdf

http://effectivehealthcare.ahrq.gov/ehc/products/325/1304/EvidenceReport208_CQGPalliativeCare_ExecutiveSummary_20121024.pdf

http://effectivehealthcare.ahrq.gov/ehc/products/325/1304/EvidenceReport208_CQGPalliativeCare_ExecutiveSummary_20121024.pdf

http://www.qualityforum.org/Publications/2012/04/Palliative_Care_and_End-of-Life_Care%e2%80%94A_Consensus_Report.aspx

http://www.qualityforum.org/Publications/2012/04/Palliative_Care_and_End-of-Life_Care%e2%80%94A_Consensus_Report.aspx









Attachment A

Domains of Clinical Evidence of Decline Clinical Status • Decreased appetite/ food consumption • Body mass measurement • Functional status • Infections, persistent • Psychological state • Recurrent aspiration • Social status (change in social

support/relationships) • Weight change resulting from disease

Signs • Agitation • Ascites • Circulatory obstructions resulting from disease • Decrease systolic BP < 90 or progressive

postural hypotension • Decubitus • Edema • Heart rate • Level of consciousness • Pathologic fracture • Pleural/ pericardial effusion • Respiratory rate, pattern • Skin color • Urine output • Weakness

Symptoms • Cough • Diarrhea/constipation • Dyspnea • Fatigue • Nausea/vomiting • Pain • Seizure/CNS activity • Swallowing/dysphagia

Labs • Arterial blood gases/pulse oximetry • CBC • Electrolyte balance • Metabolic studies • Prealbumin, albumin or cholesterol resulting

from disease • Tumor markers

Other Indicators • Change in Karnofsky Performance Status (KPS) resulting from disease • Decline in Functional Assessment Staging Test (FAST) dementia members, only • Medication adjustment • Identification/development of new/persistent/change in comorbidities • Usage of continuous, respite, general inpatient hospice care • Independence • Skin integrity

PreferredOne Community Health Plan (“PCHP”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

PCHP:Provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages

If you need these services, contact a Grievance Specialist.

If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Grievance SpecialistPreferredOne Community Health PlanPO Box 59052Minneapolis, MN 55459-0052Phone: 1.800.940.5049 (TTY: 763.847.4013)Fax: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

PreferredOne Community Health Plan Nondiscrimination Notice

Language Assistance Services

NDR PCHP LV (10/16)

PreferredOne Insurance Company (“PIC”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

PIC:Provides free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages

If you need these services, contact a Grievance Specialist.

If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Grievance SpecialistPreferredOne Insurance CompanyPO Box 59212Minneapolis, MN 55459-0212Phone: 1.800.940.5049 (TTY: 763.847.4013)Fax: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

PreferredOne Insurance Company Nondiscrimination Notice

Language Assistance Services

NDR PIC LV (10/16)

date approved: integrated healthcare services … community health plan (pchp) ... mc/n007 skilled...

Documents