[Federal Register Volume 60, Number 21 (Wednesday, February 1, 1995)]
[Rules and Regulations]
[Pages 6013-6021]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-2194]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
RIN-0720-AA18
[DoD 6010.8-R]
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS); Hospice Care
AGENCY: Office of the Secretary, DoD.
ACTION: Final rule.
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SUMMARY: This final rule revises DoD 6010.8-R which implements the
Civilian Health and Medical Program of the Uniformed Services. The rule
establishes a hospice benefit for the terminally ill that offers an
alternative to traditional therapeutic treatment which may no longer be
appropriate or desirable. Hospice care is palliative rather than
curative, generally emphasizing home care rather than institutional
care, and treating the social, psychological, spiritual, and physical
needs of the entire family.
EFFECTIVE DATE: This final rule is effective June 1, 1995.
ADDRESSES: Office of the Civilian Health and Medical Program of the
Uniformed Service (OCHAMPUS), Program Development Branch, Aurora, CO
80045-6900.
FOR FURTHER INFORMATION CONTACT:
David Bennett, Program Development Branch, OCHAMPUS, Aurora, Colorado
80045-6900, telephone (303) 361-1094.
SUPPLEMENTARY INFORMATION: In FR Doc. 93-21950, appearing in the
Federal Register on September 10, 1993 (58 FR 47692), The Office of the
Secretary of Defense published for public comment a proposed rule
establishing a hospice benefit under CHAMPUS.
Background
The Defense Authorization Act for FY 1992-93, Public Law 102-190,
directed CHAMPUS to provide hospice care in the manner and under the
conditions provided in section 1861(dd) of the Social Security Act (42
U.S.C. 1395x(dd)). This section of the Social Security Act sets forth
coverage/benefit guidelines, along with certification criteria for
participation in a hospice program. Since it is Congress' specific
intent to establish a benefit identical to that of Medicare, CHAMPUS
has adopted the provisions currently set out in Medicare's hospice
coverage/benefit guidelines, reimbursement methodologies (including
national hospice rates and wage indices), and certification criteria
for participation in [[Page 6014]] the hospice program (42 CFR Part
418, Hospice Care).
Under these provisions CHAMPUS will provide palliative care to
individuals with prognoses of less than 6 months to live if the illness
runs its normal course. The benefit is based upon a patient and family-
centered model where the views of the patient and family or friends
figure predominantly in the care decisions. This type of care
emphasizes supportive services, such as pain control and home care,
rather than cure-oriented services provided in institutions that are
otherwise the primary focus under CHAMPUS.
CHAMPUS will use the following national Medicare hospice rates for
services provided on or after October 1, 1994, through September 30,
1995, along with the wage and nonwage components of each:
----------------------------------------------------------------------------------------------------------------
National Wage Nonwage
rate component component
----------------------------------------------------------------------------------------------------------------
Routine Home Care........................................................ $90.51 $62.19 $28.32
Continuous Home Care..................................................... 528.30 362.99 165.31
Inpatient Respite........................................................ 93.63 50.68 42.95
General Inpatient........................................................ 402.67 257.75 144.92
----------------------------------------------------------------------------------------------------------------
The rates are based on a cost-related prospective payment method
subject to a ``cap'' amount and will be adjusted annually by the
Medicare hospital market basket inflation factor for services rendered
on or after October 1 of each fiscal year. These national payment rates
will be adjusted for regional wage differences by using appropriate
Medicare area wage indices. The hospice will be reimbursed for an
amount applicable to the type and intensity of the services furnished
to the beneficiary on a particular day. The Medicare statutory cap
amount for the cap year ending October 31, 1994, is $12,846. Annual
adjustments to the cap amount will be the same as Medicare.
Hospice care is viewed as the most cost-effective form of treatment
for the terminally ill. The benefit lowers costs by reducing or
eliminating inpatient days, unnecessary tests, and expensive curative
therapies. The national rate system is designed to reimburse the
hospice for the costs of all covered services related to the treatment
of the beneficiary's terminal illness, including the administrative and
general supervisory activities performed by physicians who are
employees of, or working under arrangements made with, the hospice.
Review of Comments
As a result of the publication of the proposed rule, the following
comments were received from interested associations and agencies.
Comment 1. One commentor felt that it would be unfair for OCHAMPUS
to apply Medicare aggregate reimbursement limitations to individual
hospices since the CHAMPUS beneficiary population is only a fraction of
the Medicare population. It was their contention that the volume of
Medicare patients is sufficiently large to allow for the development of
average inpatient stay, and average cost per patient, whereas the
volume of CHAMPUS patients in any one hospice would be so small as to
potentially result in a skewed average; e.g., a hospice may have a
small percentage of CHAMPUS patients who either have longer lengths of
stay or require substantial amounts of inpatient care.
As was previously stated, it was Congress' intent for CHAMPUS to
provide hospice care in the manner and under the conditions provided in
section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)).
Paragraph (2)(A)(iii) of this section requires assurance that the
aggregate number of inpatient days does not exceed 20 percent of the
aggregate number of days during the cap period. The only practical way
of assuring this requirement is to incorporate it as part of the
overall reimbursement methodology.
The aggregate limitations also lend themselves to the basic hospice
philosophy of emphasizing home care over institutional care. The cap
and inpatient limitations provide a financial incentive for home care
delivery under the hospice all-inclusive prospective payment system.
Elimination of such incentives might inadvertently result in
overutilization of inpatient care (both respite and general inpatient
care).
There could also be the assumption that since CHAMPUS beneficiaries
constitute a younger population, their hospice care would be more
conducive to a non-institutional setting (home health care setting)
than the traditional Medicare population. Factors such as patient
mobility and availability of family/care-givers would facilitate
treatment in the home setting, thus reducing total expenditures and
inpatient days for CHAMPUS beneficiaries.
Although the commenter's assumption that the vast majority of
individual hospices will service only a very small number of CHAMPUS
beneficiaries may be valid, there may be those with significant volumes
due to the concentration of military personnel in select geographic
locations. These programs may provide care for the vast majority of
CHAMPUS beneficiaries electing hospice care.
Comment 2. As part of the previous comment, it was recommended that
the proposed CHAMPUS regulation, section 199.14, paragraph
(g)(5)(D)(ii), be modified to make it clear that inpatient days in
excess of the 80-20 rule be paid as routine home care days when
calculating the amount refunded to CHAMPUS.
Procedural guidelines have been incorporated under section 199.14,
paragraph (g)(4) describing the calculation of amounts in excess of the
inpatient limitation which must be refunded to CHAMPUS. Paragraph
(g)(4)(i)(C) of this section specifies that the actual inpatient days
in excess of the limitation (20 percent of the aggregate inpatient
days) will be paid at the routine home rate when calculating the amount
refunded to CHAMPUS.
Comment 3. One commentor felt that CHAMPUS should not require
hospice programs to collect copayments for outpatient drugs/biologicals
and respite care since their collection was optional under Medicare and
would impose an undue administration burden on those hospice programs
which do not currently have a billing system in place for copayments.
Section 199.14, paragraph (g)(8) has been revised to make the
collection of cost-shares of outpatient drugs/biologicals and respite
care option under CHAMPUS.
Comment 4. Several commentors questioned the accuracy of the
calculations in Table IV of the Supplementary Information section of
the rule.
There was a transposition error in the example. The adjusted wage
component of $58.91 calculated in the first line of the table should
have been added to the [[Page 6015]] nonwage component of $39.50 to
arrive at the adjusted rate of $98.41. The adjusted rate should then
have been divided by .95 to figure the rate for inpatient respite care
including the coinsurance ($103.59) and multiplied by .05 to arrive at
a cost-share of $5.18.
Comment 5. Several commenters felt that the combining of core
service and 24-hour availability requirements caused confusion and led
to the interpretation that drugs and biologicals, as non-core service,
did not have to be routinely available on a 24-hour basis.
The core service and 24-hour availability requirements have been
separated in order to alleviate the apparent confusion over drugs and
biologicals. Refer to section 199.4 paragraphs (e)(19)(ii) through (iv)
for revisions.
Comment 6. One commentor pointed out the draft CHAMPUS regulatory
language does not say exactly what the Medicare regulations do
concerning core services, substantially all of which must be routinely
provided by employees of the hospice, and those services the hospice
must make routinely available on a 24-hour basis. The commentor felt
that these subtle distinctions/differences might cause confusion and
differing interpretations.
Section 199.4, paragraphs (e)(19)(ii) and (iv) have been revised to
reflect current Medicare language regarding core service and 24-hour
availability requirements.
Comment 7. Several commentors indicated that section 199.4,
paragraphs (e)(19)(iv) and (v)(B)(1) of the proposed rule did not say
that the benefit periods may be elected separately at different times
as specified in the Medicare hospice regulations. It was recommended
that language be added to the referenced sections to clarify that
breaks between benefit periods will also be allowed under CHAMPUS.
Section 199.4, paragraph (e)(19)(vi)(B)(1) has been revised to
indicate that periods of care may be elected separately at different
times.
Comment 8. One commentor expressed concern that the preamble
language, as well as the proposed regulatory language, left uncertainty
regarding whether OCHAMPUS will adopt future changes to the Medicare
hospice benefit for its own CHAMPUS benefit so that the two benefits
remain nearly identical. It was felt that a divergence in standards
between the two programs could cause confusion and adversely affect a
hospice's ability to serve CHAMPUS patients.
It is OCHAMPUS' intent to maintain a hospice benefit similar to, if
not identical to, that of Medicare. This includes the adoption of all
future changes in the Medicare hospice conditions of participation.
Comment 9. One commentor felt that it was important that OCHAMPUS
confirm that it intends to use the most current Medicare rates to
reimburse hospices for services provided to CHAMPUS beneficiaries and
to adopt changes in the Medicare reimbursement methodology as they
occur; e.g., Medicare's adoption of an updated, more accurate wage
index. The commentor recommended that regulatory language be added to
section 199.14, paragraph (g) confirming CHAMPUS' intent to adopt
future changes in the Medicare reimbursement methodology.
It is CHAMPUS' intent to use the most current Medicare rates to
reimburse hospices for services to CHAMPUS beneficiaries and to adopt
all changes to the Medicare reimbursement methodology as they occur.
Regulatory language has been added to section 199.14 confirming
CHAMPUS' intention of adopting future changes in the Medicare
reimbursement methodology (refer to section 199.14, paragraph (g)(2)).
Comment 10. Several commentors felt there was an inconsistency
between the preamble and proposed regulatory language regarding the
patient's initial certification. It was pointed out that while section
199.4, paragraph (e)(19)(v)(A) requires the patient's initial
certification to be provided in writing by the patient's attending
physician (if there is one) and the hospice medical director or a
physician member of the hospice interdisciplinary group, the preamble
indicated that written certification must be provided in writing by the
attending physician and/or the hospice medical director or a physician
member of the hospice interdisciplinary group. The commentor felt that
the use of ``and/or'' incorrectly suggested that either the attending
physician or the medical director's certification is sufficient for the
initial certification.
The patient's initial 90-day certification must be provided in
writing by both the patient's attending physician (if there is one) and
the hospice medical director or physician member of the hospice
interdisciplinary group. For subsequent periods the only requirement is
certification by the medical director of the hospice or the physician
member of the hospice interdisciplinary group.
Comment 11. One commentor recommended that the definition of
hospice care at Sec. 199.2, paragraph (b) and at Sec. 199.4, paragraph
(e)(19) be amended to add ``palliative care'' to the sentence: ``This
type of care emphasizes [palliative care] and supportive service * *
*.''
The recommendation has been adopted and incorporated into the final
rule.
Comment 12. Several commentors recommended that the term ``nursing
home'' be changed to Medicaid-certified nursing facility in Sec. 199.4,
paragraph (e)(19)(i)(H).
The commentors' recommendation was adopted and incorporated into
the final rule.
Comment 13. One commentor felt that a cross-reference to the
Medicare home health agency conditions of participation, 42 CFR 484.36,
would be helpful in defining the term ``qualified'' aides in
Sec. 199.4, paragraph (e)(19)(i)(E).
A cross-reference has been provided in a note following Sec. 199.4,
paragraph (e)(19)(i)(E) which will help in defining the term
``qualified'' home health aide.
Comment 14. One commentor felt that the last sentence in proposed
Sec. 199.4, paragraph (e)(19)(i)(F) was not necessary and would only
cause confusion since each of the covered services enumerated in
Sec. 199.4, paragraphs (e)(19)(i) (A)-(H) are covered only if the
service or item is included in the patient's plan of care.
The last sentence has been deleted from the final rule.
Comment 15. One commentor pointed out that Medicare policy defines
``terminal'' as six months or less if the disease runs its normal
course.
The definition of ``terminal'' has been expanded wherever cited in
the final regulation.
Comment 16. One commentor recommended that the requirement that the
hospice must maintain professional management of the patient at all
times be expanded to include ``and in all settings.''
The recommendation was adopted and incorporated into the final
rule.
Comment 17. One commentor wanted clarification regarding the word
``participating'' in Sec. 199.4, paragraph (e)(19)(i)(H).
A hospice program must be Medicare approved (i.e., a state agency
must certify to the Department of Health and Human Services that a
hospice meets the conditions of participation established in 42 CFR
Part 418--Hospice Care) in order to participate in the CHAMPUS program.
The hospice will only be allowed to participate (enter into a
participation agreement with CHAMPUS) if there is proof that it is a
Medicare approved facility. Respite care is the only type of inpatient
care that may be provided in a nursing [[Page 6016]] facility (formally
known as an intermediate care facility--ICF). A nursing facility must
be certified by a state Medicaid agency as well as meet the conditions
for participation under 42 CFR 418.100 in order to participate in
CHAMPUS.
Comment 18. One commentor pointed out that CHAMPUS' requirement
that short-term inpatient care be provided in Medicare participating
facilities precludes/prohibits the coverage of inpatient care in VA
hospitals.
Hospice care will not be allowed in VA hospitals under the
provisions of this rule.
Comment 19. One commenter wanted to know if CHAMPUS intended to use
the Health Care Financing Administration's (HCFA) wage index
adjustments for hospice reimbursement.
Yes, CHAMPUS intends to use HCFA's wage index adjustments for
hospice reimbursement. These wage indices have been in use since the
inception of the Medicare hospice benefit in 1983, and are different
than those used in calculation of CHAMPUS DRGs and mental health per
diems.
Comment 20. Several editorial comments were received from one of
CHAMPUS' administrative agencies.
All of these comments were adopted and incorporated into the final
rule.
Summary of Regulatory Modifications
The following modifications were made as a result of suggestions
received during the public comment period:
(1) The core services and 24-hour availability requirements were
separated out as distinct provisions;
(2) the collection of cost-shares by individual hospices for
outpatient drugs/biologicals and respite care was made optional under
CHAMPUS; (3) regulatory language was added confirming CHAMPUS's
intention of adopting future changes in Medicare reimbursement
methodology; (4) procedures were added for changes in designation of
hospice programs; (5) exceptions were provided for waiver of payment of
other basic program services related to treatment of terminal illness;
(6) a note was added regarding the information required on the
treatment plan; and (7) payment provisions were modified to allow 100
percent payment of CHAMPUS allowed charges for hospice physicians
providing direct patient care.
Provider Notification
The CHAMPUS contractors will be sending out letters along with
CHAMPUS participation agreements, on a one time basis, to all hospice
programs certified to participate in Medicare within their
jurisdictional areas. The letters will provide information regarding
the new hospice benefit and encourage participation under CHAMPUS. A
hospice program will be certified based solely on its appearance on a
current Medicare listing. No additional information will be required
except for the signed CHAMPUS participation agreement which accompanied
the notification letter. Thereafter, hospice programs will have to
contact the CHAMPUS contractor responsible for claims processing within
their geographical area for certification under CHAMPUS. The hospice
will have to provide documentation that it is certified to participate
in Medicare (i.e., it meets all Medicare conditions of participation
(42 CFR Part 418) relative to CHAMPUS beneficiaries) and that it and
its employees are licensed in accordance with applicable Federal, State
and local laws and regulations. The hospice will be provided with a
participation agreement for signature if the above requirements are
met. An agreement with a hospice is not time-limited and has no fixed
expiration date. The agreement remains in effect until such time as
there is a voluntary or involuntary termination.
Regulatory Procedures
Executive Order 12866 requires that a regulatory impact analysis be
performed on any significant action. A ``significant action'' is
defined as one which would result in an annual effect on the national
economy of $100 million or more, or which would have other substantial
impacts.
The Regulatory Flexibility Act (RFA) requires that each federal
agency prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation which would
have a significant impact on a substantial number of small entities.
This final rule is not a major rule under Executive Order 12866.
The changes set forth in this final rule are minor revisions to
existing regulation. The changes made in this final rule involve an
expansion of CHAMPUS benefits. In addition, this final rule will have
minor impact and will not significantly affect a substantial number of
small entities. In light of the above, no regulatory impact analysis is
required.
We certify that this final rule has been reviewed under the
provisions of the October 23, 1991, Executive Order on Civil Justice
Reform. This final rule meets all applicable standards provided in that
executive order.
This rule does impose minimal information collection requirements
to include the following: (1) Total number of CHAMPUS inpatient hospice
days; (2) total number of CHAMPUS hospice days (both inpatient and home
care); (3) total number of CHAMPUS beneficiaries electing hospice care;
(4) total reimbursement for CHAMPUS inpatient care; and (5) total
reimbursement for all CHAMPUS hospice care (both inpatient and home
care).
The fact that all CHAMPUS-approved hospice programs are subject to
Medicare reporting requirements (i.e., they must be Medicare certified
in order to receive CHAMPUS reimbursement), will tend to minimize the
administrative burden imposed by this rule. The hospice will already
have an established data collection system in place for developing
these annual reports. Overall, resource allocation (administrative
time) will be minimal since the number of CHAMPUS hospice beneficiaries
would be disproportionately low compared to the number of Medicare
patients. In other words, since the facility already has to collect,
arrange, and submit the data on a majority of its patients, the
administrative costs and/or burden of reporting CHAMPUS hospice
patients would be minimal. The hospice would have to expand only the
data collection parameters (data on CHAMPUS beneficiaries) in order to
meet the requirements under this rule.
The rule represents an expansion of benefits under the CHAMPUS
program, resulting in certification of a new provider category
(hospice). Although hospice programs are accustomed to the proposed
reporting requirements and would not view this as an administrative
intrusion, the final rule has been prepared for review by the Executive
Office of Management and Budget under authority of the Paperwork
Reduction Act of 1980 (44 U.S.C. 3501-3520.
List of Subjects in 32 CFR Part 199
Claims, handicapped, health insurance, and military personnel.
Accordingly, 32 CFR part 199, is amended as follows:
PART 199--CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED
SERVICES (CHAMPUS)
1. The authority citation for Part 199 continues to read as
follows:
Authority: 5 U.S.C. 301; 10 U.S.C. 1079, 1086.
2. Section 199.2(b) is amended by adding a definition for ``hospice
care'' [[Page 6017]] and ``respite care'' in alphabetical order to read
as follows:
Sec. 199.2 Definitions.
* * * * *
(b) * * *
Hospice care. Hospice care is a program which provides an
integrated set of services and supplies designed to care for the
terminally ill. This type of care emphasizes palliative care and
supportive services, such as pain control and home care, rather than
cure-oriented services provided in institutions that are otherwise the
primary focus under CHAMPUS. The benefit provides coverage for a humane
and sensible approach to care during the last days of life for some
terminally ill patients.
* * * * *
Respite care. Respite care is short-term care for a patient in
order to provide rest and change for those who have been caring for the
patient at home, usually the patient's family.
* * * * *
3. Section 199.4 is amended by adding new paragraph (e)(19) to read
as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(e) * * *
(19) Hospice care. Hospice care is a program which provides an
integrated set of services and supplies designed to care for the
terminally ill. This type of care emphasizes palliative care and
supportive services, such as pain control and home care, rather than
cure-oriented services provided in institutions that are otherwise the
primary focus under CHAMPUS. The benefit provides coverage for a humane
and sensible approach to care during the last days of life for some
terminally ill patients.
(i) Benefit coverage. CHAMPUS beneficiaries who are terminally ill
(that is, a life expectancy of six months or less if the disease runs
its normal course) will be eligible for the following services and
supplies in lieu of most other CHAMPUS benefits:
(A) Physician services.
(B) Nursing care provided by or under the supervision of a
registered professional nurse.
(C) Medical social services provided by a social worker who has at
least a bachelor's degree from a school accredited or approved by the
Council on Social Work Education, and who is working under the
direction of a physician. Medical social services include, but are not
limited to the following:
(1) Assessment of social and emotional factors related to the
beneficiary's illness, need for care, response to treatment, and
adjustment to care.
(2) Assessment of the relationship of the beneficiary's medical and
nursing requirements to the individual's home situation, financial
resources, and availability of community resources.
(3) Appropriate action to obtain available community resources to
assist in resolving the beneficiary's problem.
(4) Counseling services that are required by the beneficiary.
(D) Counseling services provided to the terminally ill individual
and the family member or other persons caring for the individual at
home. Counseling, including dietary counseling, may be provided both
for the purpose of training the individual's family or other care-giver
to provide care, and for the purpose of helping the individual and
those caring for him or her to adjust to the individual's approaching
death. Bereavement counseling, which consists of counseling services
provided to the individual's family after the individual's death, is a
required hospice service but it is not reimbursable.
(E) Home health aide services furnished by qualified aides and
homemaker services. Home health aides may provide personal care
services. Aides also may perform household services to maintain a safe
and sanitary environment in areas of the home used by the patient.
Examples of such services are changing the bed or light cleaning and
laundering essential to the comfort and cleanliness of the patient.
Aide services must be provided under the general supervision of a
registered nurse. Homemaker services may include assistance in personal
care, maintenance of a safe and healthy environment, and services to
enable the individual to carry out the plan of care. Qualifications for
home health aides can be found in 42 CFR 484.36.
(F) Medical appliances and supplies, including drugs and
biologicals. Only drugs that are used primarily for the relief of pain
and symptom control related to the individual's terminal illness are
covered. Appliances may include covered durable medical equipment, as
well as other self-help and personal comfort items related to the
palliation or management of the patient's condition while he or she is
under hospice care. Equipment is provided by the hospice for use in the
beneficiary's home while he or she is under hospice care. Medical
supplies include those that are part of the written plan of care.
Medical appliances and supplies are included within the hospice all-
inclusive rates.
(G) Physical therapy, occupational therapy and speech-language
pathology services provided for purposes of symptom control or to
enable the individual to maintain activities of daily living and basic
functional skills.
(H) Short-term inpatient care provided in a Medicare participating
hospice inpatient unit, or a Medicare participating hospital, skilled
nursing facility (SNF) or, in the case of respite care, a Medicaid-
certified nursing facility that additionally meets the special hospice
standards regarding staffing and patient areas. Services provided in an
inpatient setting must conform to the written plan of care. Inpatient
care may be required for procedures necessary for pain control or acute
or chronic symptom management. Inpatient care may also be furnished to
provide respite for the individual's family or other persons caring for
the individual at home. Respite care is the only type of inpatient care
that may be provided in a Medicaid-certified nursing facility. The
limitations on custodial care and personal comfort items applicable to
other CHAMPUS services are not applicable to hospice care.
(ii) Core services. The hospice must ensure that substantially all
core services are routinely provided directly by hospice employees;
i.e., physician services, nursing care, medical social services, and
counseling for individuals and care givers. Refer to paragraphs
(e)(19)(i)(A), (e)(19)(i)(B), (e)(19)(i)(C), and (e)(19)(i)(D) of this
section.
(iii) Non-core services. While non-core services (i.e., home health
aide services, medical appliances and supplies, drugs and biologicals,
physical therapy, occupational therapy, speech-language pathology and
short-term inpatient care) may be provided under arrangements with
other agencies or organizations, the hospice must maintain professional
management of the patient at all times and in all settings. Refer to
paragraphs (e)(19)(i)(E), (e)(19)(i)(F), (e)(19)(i)(G), and
(e)(19)(i)(H) of this section.
(iv) Availability of services. The hospice must make nursing
services, physician services, and drugs and biologicals routinely
available on a 24-hour basis. All other covered services must be made
available on a 24-hour basis to the extent necessary to meet the needs
of individuals for care that is reasonable and necessary for the
palliation and management of the terminal illness and related
condition. These services must be provided in a [[Page 6018]] manner
consistent with accepted standards of practice.
(v) Periods of care. Hospice care is divided into distinct periods/
episodes of care. The terminally ill beneficiary may elect to receive
hospice benefits for an initial period of 90 days, a subsequent period
of 90 days, a second subsequent period of 30 days, and a final period
of unlimited duration.
(vi) Conditions for coverage. The CHAMPUS beneficiary must meet the
following conditions/criteria in order to be eligible for the hospice
benefits and services referenced in paragraph (e)(19)(i) of this
section.
(A) There must be written certification in the medical record that
the CHAMPUS beneficiary is terminally ill with a life expectancy of six
months or less if the terminal illness runs its normal course.
(1) Timing of certification. The hospice must obtain written
certification of terminal illness for each of the election periods
described in paragraph (e)(19(vi)(B) of this section, even if a single
election continues in effect for two, three or four periods.
(i) Basic requirement. Except as provided in paragraph
(e)(19(vi)(A)(1)(ii) of this section the hospice must obtain the
written certification no later than two calendar days after the period
begins.
(ii) Exception. For the initial 90-day period, if the hospice
cannot obtain the written certifications within two calendar days, it
must obtain oral certifications within two calendar days, and written
certifications no later than eight calendar days after the period
begins.
(2) Sources of certification. Physician certification is required
for both initial and subsequent election periods.
(i) For the initial 90-day period, the hospice must obtain written
certification statements (and oral certification statements if required
under paragraph (e)(19(vi)(A)(i)(ii) of this section) from:
(A) The individual's attending physician if the individual has an
attending physician; and
(B) The medical director of the hospice or the physician member of
the hospice interdisciplinary group.
(ii) For subsequent periods, the only requirement is certification
by one of the physicians listed in paragraph (e)(19)(vi)(A)(2)(i)(B) of
this section.
(B) The terminally ill beneficiary must elect to receive hospice
care for each specified period of time; i.e., the two 90-day periods, a
subsequent 30-day period, and a final period of unlimited duration. If
the individual is found to be mentally incompetent, his or her
representative may file the election statement. Representative means an
individual who has been authorized under State law to terminate medical
care or to elect or revoke the election of hospice care on behalf of a
terminally ill individual who is found to be mentally incompetent.
(1) The episodes of care must be used consecutively; i.e., the two
90-day periods first, then the 30-day period, followed by the final
period. The periods of care may be elected separately at different
times.
(2) The initial election will continue through subsequent election
periods without a break in care as long as the individual remains in
the care of the hospice and does not revoke the election.
(3) The effective date of the election may begin on the first day
of hospice care or any subsequent day of care, but the effective date
cannot be made prior to the date that the election was made.
(4) The beneficiary or representative may revoke a hospice election
at any time, but in doing so, the remaining days of that particular
election period are forfeited and standard CHAMPUS coverage resumes. To
revoke the hospice benefit, the beneficiary or representative must file
a signed statement of revocation with the hospice. The statement must
provide 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.
(5) If an election of hospice benefits has been revoked, the
individual, or his or her representative may at any time file a hospice
election for any period of time still available to the individual, in
accordance with Sec. 199.4(e)(19)(vi)(B).
(6) A CHAMPUS beneficiary may change, once in each election period,
the designation of the particular hospice from which he or she elects
to receive hospice care. 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:
(i) 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.
(ii) The date the change is to be effective.
(7) Each hospice will design and print its own election statement
to include the following information:
(i) Identification of the particular hospice that will provide care
to the individual.
(ii) The individual's or representative's acknowledgment 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.
(iii) The individual's or representative's acknowledgment that he
or she understands that certain other CHAMPUS services are waived by
the election.
(iv) The effective date of the election.
(v) The signature of the individual or representative, and the date
signed.
(8) The hospice must notify the CHAMPUS contractor of the
initiation, change or revocation of any election.
(c) The beneficiary must waive all rights to other CHAMPUS payments
for the duration of the election period for:
(1) Care provided by any hospice program other than the elected
hospice unless provided under arrangements made by the elected hospice;
and
(2) Other CHAMPUS basic program services/benefits related to the
treatment of the terminal illness for which hospice care was elected,
or to a related condition, or that are equivalent to hospice care,
except for services provided by:
(i) the designated hospice;
(ii) another hospice under arrangement made by the designated
hospice; or
(iii) an attending physician who is not employed by or under
contract with the hospice program.
(3) Basic CHAMPUS coverage will be reinstated upon revocation of
the hospice election.
(D) A written plan of care must be established by a member of the
basic interdisciplinary group assessing the patient's needs. This group
must have at least one physician, one registered professional nurse,
one social worker, and one pastoral or other counselor.
(1) In establishing the initial plan of care the member of the
basic interdisciplinary group who assesses the patient's needs must
meet or call at least one other group member before writing the initial
plan of care.
(2) At least one of the persons involved in developing the initial
plan must be a nurse or physician.
(3) The plan must be established on the same day as the assessment
if the day of assessment is to be a covered day of hospice care.
(4) The other two members of the basic interdisciplinary group--the
attending physician and the medical director or physician designee--
must review the initial plan of care and provide their input to the
process of establishing the plan of care within two
[[Page 6019]] calendar days following the day of assessment. A meeting
of group members is not required within this 2-day period. Input may be
provided by telephone.
(5) Hospice services must be consistent with the plan of care for
coverage to be extended.
(6) The plan must be reviewed and updated, at intervals specified
in the plan, by the attending physician, medical director or physician
designee and interdisciplinary group. These reviews must be documented
in the medical records.
(7) The hospice must designate a registered nurse to coordinate the
implementation of the plan of care for each patient.
(8) The plan must include an assessment of the individual's needs
and identification of the services, including the management of
discomfort and symptom relief. It must state in detail the scope and
frequency of services needed to meet the patient's and family's needs.
(E) Complete medical records and all supporting documentation must
be submitted to the CHAMPUS contractor within 30 days of the date of
its request. If records are not received within the designated time
frame, authorization of the hospice benefit will be denied and any
prior payments made will be recouped. A denial issued for this reason
is not an initial determination under section 199.10, and is not
appealable.
(vii) Appeal rights under hospice benefit. A beneficiary or
provider is entitled to appeal rights for cases involving a denial of
benefits in accordance with the provisions of this part and part
199.10.
* * * * *
4. Section 199.6 is amended by adding new paragraph (b)(4)(xiii) to
read as follows:
Sec. 199.6 Authorized providers.
* * * * *
(b) * * *
(4) * * *
(xiii) Hospice programs. Hospice programs must be Medicare approved
and meet all Medicare conditions of participation (42 CFR Part 418) in
relation to CHAMPUS patients in order to receive payment under the
CHAMPUS program. A hospice program may be found to be out of compliance
with a particular Medicare condition of participation and still
participate in the CHAMPUS as long as the hospice is allowed continued
participation in Medicare while the condition of noncompliance is being
corrected. The hospice program can be either a public agency or private
organization (or a subdivision thereof) which:
(A) Is primarily engaged in providing the care and services
described under Sec. 199.4(e)(19) and makes such services available on
a 24-hour basis.
(B) Provides bereavement counseling for the immediate family or
terminally ill individuals.
(C) Provides for such care and services in individuals' homes, on
an outpatient basis, and on a short-term inpatient basis, directly or
under arrangements made by the hospice program, except that the agency
or organization must:
(1) Ensure that substantially all the core services are routinely
provided directly by hospice employees.
(2) Maintain professional management responsibility for all
services which are not directly furnished to the patient, regardless of
the location or facility in which the services are rendered.
(3) Provide assurances that the aggregate number of days of
inpatient care provided in any 12-month period does not exceed 20
percent of the aggregate number of days of hospice care during the same
period.
(4) Have an interdisciplinary group composed of the following
personnel who provide the care and services described under
Sec. 199.4(e)(19) and who establish the policies governing the
provision of such care/services:
(i) A physician;
(ii) A registered professional nurse;
(iii) A social worker; and
(iv) A pastoral or other counselor.
(5) Maintain central clinical records on all patients.
(6) Utilize volunteers.
(7) The hospice and all hospice employees must be licensed in
accordance with applicable Federal, State and local laws and
regulations.
(8) The hospice must enter into an agreement with CHAMPUS in order
to be qualified to participate and to be eligible for payment under the
program. In this agreement the hospice and CHAMPUS agree that the
hospice will:
(i) Not charge the beneficiary or any other person for items or
services for which the beneficiary is entitled to have payment made
under the CHAMPUS hospice benefit.
(ii) Be allowed to charge the beneficiary for items or services
requested by the beneficiary in addition to those that are covered
under the CHAMPUS hospice benefit.
(9) Meet such other requirements as the Secretary of Defense may
find necessary in the interest of the health and safety of the
individuals who are provided care and services by such agency or
organization.
* * * * *
5. Section 199.14 is amended by redesignating paragraphs (g), (h),
(i), (j), and (k) as (h), (i), (j), (k), and (l), adding new paragraph
(g).
Sec. 199.14 Provider reimbursement methods.
* * * * *
(g) Reimbursement of hospice programs. Hospice care will be
reimbursed at one of four predetermined national CHAMPUS rates based on
the type and intensity of services furnished to the beneficiary. A
single rate is applicable for each day of care except for continuous
home care where payment is based on the number of hours of care
furnished during a 24-hour period. These rates will be adjusted for
regional differences in wages using wage indices for hospice care.
(1) National hospice rates. CHAMPUS will use the national hospice
rates for reimbursement of each of the following levels of care
provided by or under arrangement with a CHAMPUS approved hospice
program:
(i) Routine home care. The hospice will be paid the routine home
care rate for each day the patient is at home, under the care of the
hospice, and not receiving continuous home care. This rate is paid
without regard to the volume or intensity of routine home care services
provided on any given day.
(ii) Continuous home care. The hospice will be paid the continuous
home care rate when continuous home care is provided. The continuous
home care rate is divided by 24 hours in order to arrive at an hourly
rate.
(A) A minimum of 8 hours of care must be provided within a 24-hour
day starting and ending at midnight.
(B) More than half of the total actual hours being billed for each
24-hour period must be provided by either a registered or licensed
practical nurse.
(C) Homemaker and home health aide services may be provided to
supplement the nursing care to enable the beneficiary to remain at
home.
(D) For every hour or part of an hour of continuous care furnished,
the hourly rate will be reimbursed to the hospice up to 24 hours a day.
(iii) Inpatient respite care. The hospice will be paid at the
inpatient respite care rate for each day on which the beneficiary is in
an approved inpatient facility and is receiving respite care.
(A) Payment for respite care may be made for a maximum of 5 days at
a time, including the date of admission but not counting the date of
discharge. The [[Page 6020]] necessity and frequency of respite care
will be determined by the hospice interdisciplinary group with input
from the patient's attending physician and the hospice's medical
director.
(B) Payment for the sixth and any subsequent days is to be made at
the routine home care rate.
(iv) General inpatient care. Payment at the inpatient rate will be
made when general inpatient care is provided for pain control or acute
or chronic symptom management which cannot be managed in other
settings. None of the other fixed payment rates (i.e., routine home
care) will be applicable for a day on which the patient receives
general inpatient care except on the date of discharge.
(v) Date of discharge. For the day of discharge from an inpatient
unit, the appropriate home care rate is to be paid unless the patient
dies as an inpatient. When the patient is discharged deceased, the
inpatient rate (general or respite) is to be paid for the discharge
date.
(2) Use of Medicare rates. CHAMPUS will use the most current
Medicare rates to reimburse hospice programs for services provided to
CHAMPUS beneficiaries. It is CHAMPUS' intent to adopt changes in the
Medicare reimbursement methodology as they occur; e.g., Medicare's
adoption of an updated, more accurate wage index.
(3) Physician reimbursement. Payment is dependent on the
physician's relationship with both the beneficiary and the hospice
program.
(i) Physicians employed by, or contracted with, the hospice.
(A) Administrative and supervisory activities (i.e., establishment,
review and updating of plans of care, supervising care and services,
and establishing governing policies) are included in the adjusted
national payment rate.
(B) Direct patient care services are paid in addition to the
adjusted national payment rate.
(1) Physician services will be reimbursed an amount equivalent to
100 percent of the CHAMPUS' allowable charge; i.e., there will be no
cost-sharing and/or deductibles for hospice physician services.
(2) Physician payments will be counted toward the hospice cap
limitation.
(ii) Independent attending physician. Patient care services
rendered by an independent attending physician (a physician who is not
considered employed by or under contract with the hospice) are not part
of the hospice benefit.
(A) Attending physician may bill in his/her own right.
(B) Services will be subject to the appropriate allowable charge
methodology.
(C) Reimbursement is not counted toward the hospice cap limitation.
(D) Services provided by an independent attending physician must be
coordinated with any direct care services provided by hospice
physicians.
(E) The hospice must notify the CHAMPUS contractor of the name of
the physician whenever the attending physician is not a hospice
employee.
(iii) Voluntary physician services. No payment will be allowed for
physician services furnished voluntarily (both physicians employed by,
and under contract with, the hospice and independent attending
physicians). Physicians may not discriminate against CHAMPUS
beneficiaries; e.g., designate all services rendered to non-CHAMPUS
patients as volunteer and at the same time bill for CHAMPUS patients.
(4) Unrelated medical treatment. Any covered CHAMPUS services not
related to the treatment of the terminal condition for which hospice
care was elected will be paid in accordance with standard reimbursement
methodologies; i.e., payment for these services will be subject to
standard deductible and cost-sharing provisions under the CHAMPUS. A
determination must be made whether or not services provided are related
to the individual's terminal illness. Many illnesses may occur when an
individual is terminally ill which are brought on by the underlying
condition of the ill patient. For example, it is not unusual for a
terminally ill patient to develop pneumonia or some other illness as a
result of his or her weakened condition. Similarly, the setting of
bones after fractures occur in a bone cancer patient would be treatment
of a related condition. Thus, if the treatment or control of an upper
respiratory tract infection is due to the weakened state of the
terminal patient, it will be considered a related condition, and as
such, will be included in the hospice daily rates.
(5) Cap amount. Each CHAMPUS-approved hospice program will be
subject to a cap on aggregate CHAMPUS payments from November 1 through
October 31 of each year, hereafter known as ``the cap period.''
(i) The cap amount will be adjusted annually by the percent of
increase or decrease in the medical expenditure category of the
Consumer Price Index for all urban consumers (CPI-U).
(ii) The aggregate cap amount (i.e., the statutory cap amount times
the number of CHAMPUS beneficiaries electing hospice care during the
cap period) will be compared with total actual CHAMPUS payments made
during the same cap period.
(iii) Payments in excess of the cap amount must be refunded by the
hospice program. The adjusted cap amount will be obtained from the
Health Care Financing Administration (HCFA) prior to the end of each
cap period.
(iv) Calculation of the cap amount for a hospice which has not
participated in the program for an entire cap year (November 1 through
October 31) will be based on a period of at least 12 months but no more
than 23 months. For example, the first cap period for a hospice
entering the program on October 1, 1994, would run from October 1, 1994
through October 31, 1995. Similarly, the first cap period for hospice
providers entering the program after November 1, 1993 but before
November 1, 1994 would end October 31, 1995.
(6) Inpatient limitation. During the 12-month period beginning
November 1 of each year and ending October 31, the aggregate number of
inpatient days, both for general inpatient care and respite care, may
not exceed 20 percent of the aggregate total number of days of hospice
care provided to all CHAMPUS beneficiaries during the same period.
(i) If the number of days of inpatient care furnished to CHAMPUS
beneficiaries exceeds 20 percent of the total days of hospice care to
CHAMPUS beneficiaries, the total payment for inpatient care is
determined follows:
(A) Calculate the ratio of the maximum number of allowable
inpatient days of the actual number of inpatient care days furnished by
the hospice to Medicare patients.
(B) Multiply this ratio by the total reimbursement for inpatient
care made by the CHAMPUS contractor.
(C) Multiply the number of actual inpatient days in excess of the
limitation by the routine home care rate.
(D) Add the amounts calculated in paragraphs (g)(6)(i) (B) and (C)
of this section.
(ii) Compare the total payment for inpatient care calculated in
paragraph (g)(6)(i)(D) of this section to actual payments made to the
hospice for inpatient care during the cap period.
(iii) Payments in excess of the inpatient limitation must be
refunded by the hospice program.
(7) Hospice reporting responsibilities. The hospice is responsible
for reporting the following data within 30 days after the end of the
cap period: [[Page 6021]]
(i) Total reimbursement received and receivable for services
furnished CHAMPUS beneficiaries during the cap period, including
physician's services not of an administrative or general supervisory
nature.
(ii) Total reimbursement received and receivable for general
inpatient care and inpatient respite care furnished to CHAMPUS
beneficiaries during the cap period.
(iii) Total number of inpatient days furnished to CHAMPUS hospice
patients (both general inpatient and inpatient respite days) during the
cap period.
(iv) Total number of CHAMPUS hospice days (both inpatient and home
care) during the cap period.
(v) Total number of beneficiaries electing hospice care. The
following rules must be adhered to by the hospice in determining the
number of CHAMPUS beneficiaries who have elected hospice care during
the period:
(A) The beneficiary must not have been counted previously in either
another hospice's cap or another reporting year.
(B) The beneficiary must file an initial election statement during
the period beginning September 28 of the previous cap year through
September 27 of the current cap year in order to be counted as an
electing CHAMPUS beneficiary during the current cap year.
(C) Once a beneficiary has been included in the calculation of a
hospice cap amount, he or she may not be included in the cap for that
hospice again, even if the number of covered days in a subsequent
reporting period exceeds that of the period where the beneficiary was
included.
(D) There will be proportional application of the cap amount when a
beneficiary elects to receive hospice benefits from two or more
different CHAMPUS-certified hospices. A calculation must be made to
determine the percentage of the patient's length of stay in each
hospice relative to the total length of hospice stay.
(8) Reconsideration of cap amount and inpatient limit. A hospice
dissatisfied with the contractor's calculation and application of its
cap amount and/or inpatient limitation may request and obtain a
contractor review if the amount of program reimbursement in
controversy--with respect to matters which the hospice has a right to
review--is at least $1000. The administrative review by the contractor
of the calculation and application of the cap amount and inpatient
limitation is the only administrative review available. These
calculations are not subject to the appeal procedures set forth in
Sec. 199.10. The methods and standards for calculation of the hospice
payment rates established by CHAMPUS, as well as questions as to the
validity of the applicable law, regulations or CHAMPUS decisions, are
not subject to administrative review, including the appeal procedures
of Sec. 199.10.
(9) Beneficiary cost-sharing. There are no deductibles under the
CHAMPUS hospice benefit. CHAMPUS pays the full cost of all covered
services for the terminal illness, except for small cost-share amounts
which may be collected by the individual hospice for outpatient drugs
and biologicals and inpatient respite care.
(i) The patient is responsible for 5 percent of the cost of
outpatient drugs or $5 toward each prescription, whichever is less.
Additionally, the cost of prescription drugs (drugs or biologicals) may
not exceed that which a prudent buyer would pay in similar
circumstances; that is, a buyer who refuses to pay more than the going
price for an item or service and also seeks to economize by minimizing
costs.
(ii) For inpatient respite care, the cost-share for each respite
care day is equal to 5 percent of the amount CHAMPUS has estimated to
be the cost of respite care, after adjusting the national rate for
local wage differences.
(iii) The amount of the individual cost-share liability for respite
care during a hospice cost-share period may not exceed the Medicare
inpatient hospital deductible applicable for the year in which the
hospice cost-share period began. The individual hospice cost-share
period begins on the first day an election is in effect for the
beneficiary and ends with the close of the first period of 14
consecutive days on each of which an election is not in effect for the
beneficiary.
* * * * *
Dated: January 25, 1995.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 95-2194 Filed 1-31-95; 8:45 am]
BILLING CODE 5000-04-M
