42 C.F.R. Subpart B—Eligibility, Election and Duration of Benefits
Title 42 - Public Health
In order to be eligible to elect hospice care under Medicare, an individual must be— (a) Entitled to Part A of Medicare; and (b) Certified as being terminally ill in accordance with §418.22. (a) Subject to the conditions set forth in this part, an individual may elect to receive hospice care during one or more of the following election periods: (1) An initial 90-day period; (2) A subsequent 90-day period; or (3) An unlimited number of subsequent 60-day periods. (b) The periods of care are available in the order listed and may be elected separately at different times. [55 FR 50834, Dec. 11, 1990, as amended at 57 FR 36017, Aug. 12, 1992; 70 FR 70546, Nov. 22, 2005] (a) Timing of certification—(1) General rule. The hospice must obtain written certification of terminal illness for each of the periods listed in §418.21, even if a single election continues in effect for an unlimited number of periods, as provided in §418.24(c). (2) Basic requirement. Except as provided in paragraph (a)(3) of this section, the hospice must obtain the written certification before it submits a claim for payment. (3) Exception. If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment. (b) Content of certification. Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements: (1) The certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. (2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment. (c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from— (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual's attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in §410.20 of this subchapter. (2) For subsequent periods, the only requirement is certification by one of the physicians listed in paragraph (c)(1)(i) of this section. (d) Maintenance of records. Hospice staff must— (1) Make an appropriate entry in the patient's medical record as soon as they receive an oral certification; and (2) File written certifications in the medical record. [55 FR 50834, Dec. 11, 1990, as amended at 57 FR 36017, Aug. 12, 1992; 70 FR 45144, Aug. 4, 2005; 70 FR 70547, Nov. 22, 2005] (a) Filing an election statement. An individual who meets the eligibility requirement of §418.20 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her representative (as defined in §418.3) may file the election statement. (b) Content of election statement. The election statement must include the following: (1) Identification of the particular hospice that will provide care to the individual. (2) The individual's or representative's acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the individual's terminal illness. (3) Acknowledgement that certain Medicare services, as set forth in paragraph (d) of this section, are waived by the election. (4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. (5) The signature of the individual or representative. (c) Duration of election. An election to receive hospice care will be considered to continue through the initial election period and through the subsequent election periods without a break in care as long as the individual— (1) Remains in the care of a hospice; (2) Does not revoke the election; and (3) Is not discharged from the hospice under the provisions of §418.26. (d) Waiver of other benefits. For the duration of an election of hospice care, an individual waives all rights to Medicare payments for the following services: (1) Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice). (2) Any Medicare services that are 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— (i) Provided by the designated hospice: (ii) Provided by another hospice under arrangements made by the designated hospice; and (iii) Provided by the individual's attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services. (e) Re-election of hospice benefits. If an election has been revoked in accordance with §418.28, the individual (or his or her representative if the individual is mentally or physically incapacitated) may at any time file an election, in accordance with this section, for any other election period that is still available to the individual. [55 FR 50834, Dec. 11, 1990, as amended at 70 FR 70547, Nov. 22, 2005] (a) The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any). (b) In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information: (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition. (3) Current clinically relevant information supporting all diagnoses. [70 FR 70547, Nov. 22, 2005] (a) Reasons for discharge. A hospice may discharge a patient if— (1) The patient moves out of the hospice's service area or transfers to another hospice; (2) The hospice determines that the patient is no longer terminally ill; or (3) The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause that meets the requirements of paragraphs (a)(3)(i) through (a)(3)(iv) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired. The hospice must do the following before it seeks to discharge a patient for cause: (i) Advise the patient that a discharge for cause is being considered; (ii) Make a serious effort to resolve the problem(s) presented by the patient's behavior or situation; (iii) Ascertain that the patient's proposed discharge is not due to the patient's use of necessary hospice services; and (iv) Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its medical records. (b) Discharge order. Prior to discharging a patient for any reason listed in paragraph (a) of this section, the hospice must obtain a written physician's discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note. (c) Effect of discharge. An individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice— (1) Is no longer covered under Medicare for hospice care; (2) Resumes Medicare coverage of the benefits waived under §418.24(d); and (3) May at any time elect to receive hospice care if he or she is again eligible to receive the benefit. (d) Discharge planning. (1) The hospice must have in place a discharge planning process that takes into account the prospect that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill. (2) The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill. [70 FR 70547, Nov. 22, 2005] (a) An individual or representative may revoke the individual's election of hospice care at any time during an election period. (b) To revoke the election of hospice care, the individual or representative must file a statement with the hospice that includes the following information: (1) A signed statement that the individual or representative revokes the individual's election for Medicare coverage of hospice care for the remainder of that election period. (2) The date that the revocation is to be effective. (An individual or representative may not designate an effective date earlier than the date that the revocation is made). (c) An individual, upon revocation of the election of Medicare coverage of hospice care for a particular election period— (1) Is no longer covered under Medicare for hospice care; (2) Resumes Medicare coverage of the benefits waived under §418.24(e)(2); and (3) May at any time elect to receive hospice coverage for any other hospice election periods that he or she is eligible to receive. (a) An individual or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received. (b) The change of the designated hospice is not a revocation of the election for the period in which it is made. (c) To change the designation of hospice programs, the individual or representative must file, with the hospice from which care has been received and with the newly designated hospice, a statement that includes the following information: (1) The name of the hospice from which the individual has received care and the name of the hospice from which he or she plans to receive care. (2) The date the change is to be effective.
Title 42: Public Health
PART 418—HOSPICE CARE
Subpart B—Eligibility, Election and Duration of Benefits
§ 418.20 Eligibility requirements.
§ 418.21 Duration of hospice care coverage—Election periods.
§ 418.22 Certification of terminal illness.
§ 418.24 Election of hospice care.
§ 418.25 Admission to hospice care.
§ 418.26 Discharge from hospice care.
§ 418.28 Revoking the election of hospice care.
§ 418.30 Change of the designated hospice.
