Medicare hospice regulations you need to know

Hospice care is unique in the healthcare industry in that its purpose is not to cure but to simply relieve pain and discomfort for patients who are terminally ill. While these patients have a finite amount of time left with their loved ones, everyone involved in their final days of care wants them to be as comfortable as possible.

To ensure providers administer this care and comfort properly and consistently, federal and state agencies highly regulate hospices. In particular, the Centers for Medicare & Medicaid Services (CMS) has established numerous Medicare hospice regulations that facilities must abide by — whether the facilities are part of a hospital, nursing home, or home health agency.

Centers for Medicare & Medicaid Services (CMS) background

Originally established in 1977 as the Health Care Financing Administration (HCFA), the CMS changed its name in 2001. CMS is a federal agency that provides health coverage to more than 100 million people through Medicare, Medicaid, and other federal health programs.

The agency is also responsible for administering part of HIPAA and providing oversight of the federal and state health insurance exchanges. CMS is a part of the Department of Health and Human Services (HHS), a cabinet-level executive branch department of the U.S. government focused on protecting citizens’ health and providing essential human services.

CMS has four main responsibilities with regard to administering the Medicare program:

• Establish regulations and associated standards for healthcare providers
• Monitor providers through inspections (called surveys) to ensure they’re abiding by these regulations
• Ensure that providers are paid for the services they render
• Provide a process for beneficiaries to appeal healthcare decisions made by providers

If you’re interested in starting a hospice care business, it’s important that you know about not only CMS and its duties, but also its Medicare hospice regulations. Keep reading to get an overview of important regulations this agency administers.

Important Medicare hospice regulations

Regulations for hospice care are contained within the Code of Federal Regulations (CFR) — specifically Title 42, Chapter IV, Subchapter B, Part 418. The CFR is an official publication containing rules published in the Federal Register by departments and agencies of the federal government.

Part 418 — Hospice Care includes eight subparts:

• Subpart A covers general provisions and definitions.
• Subpart B covers eligibility, election, and duration of benefits.
• Subpart C covers the conditions of participation related to patient care.
• Subpart D covers conditions of participation related to the organizational environment.
• Subpart E is reserved for future use.
• Subpart F addresses covered services.
• Subpart G covers payment for hospice care.
• Subpart H covers coinsurance.

Clearly there’s a lot of ground to cover, but we’ve summarized a few key regulations below from each subpart that focuses on the hospice’s role — this excludes A, E, and H. Be sure to review Part 418 in full for specific and up-to-date regulations.

Note: The § symbol denotes a section. In this context, it’s a section in the CFR. For example, § 418.21 would be section 418.21 of the CFR.

1. Subpart B — Eligibility, election, and duration of benefits

§ 418.22 Certification of terminal illness

• Timing: Your hospice must obtain written certification of a patient’s terminal illness for each of the election periods in § 418.21 before submitting a claim for payment, with a few exceptions.
• Face-to-face encounter: Providers must have a face-to-face encounter with each hospice patient whose total stay across all hospices will reach 180 days to determine continued eligibility for hospice care. The encounter must occur prior to the end of this time period — no more than 30 calendar days prior — and must occur each subsequent 60-day period afterward.
• Certification content: Based on the provider’s clinical judgment, the certification must specify that the patient’s prognosis is for a life expectancy of six months or less if the illness runs its normal course; include clinical documentation and narrative that support the medical prognosis; attest in writing that the provider had a face-to-face encounter with the patient; and be signed and dated by the provider.

§ 418.24 Election of hospice care

• Failure to submit notice of election: If your hospice doesn’t file the required Notice of Election for its Medicare patients within five calendar days after the effective date of election, Medicare won’t cover and pay for days of hospice care from the effective date to the date of filing. There are a few exceptions, such as natural disasters or system issues deemed by CMS to be out of the control of your hospice.

2. Subpart C — Conditions of participation: Patient care

§ 418.52 Condition of participation: Patient’s rights

• Notice of rights and responsibilities: During the initial assessment visit, your hospice must provide the patient (or their representative) with verbal and written notice of the patient’s rights and responsibilities in a manner the patient understands.
• Notice regarding advance directives: Your hospice must comply with the requirements of Subpart I — Advance Directives and inform and distribute written information to the patient regarding its policies on advance directives, including a description of applicable state law.
• Patient confirmation: Your hospice must obtain the patient’s or representative’s signature confirming they’ve received a copy of the notice of rights and responsibilities.

§ 418.54 Condition of participation: Initial and comprehensive assessment of the patient

• Initial assessment: Your hospice’s registered nurse must complete an initial assessment within 48 hours after the patient elects hospice care in accordance with § 418.24.
• Comprehensive assessment: Your hospice interdisciplinary group — in consultation with the patient’s attending physician (if they have one) — must complete the comprehensive assessment no later than five calendar days after the patient elects hospice care in accordance with § 418.24. The assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process.
• Updates to the comprehensive assessment: Your hospice interdisciplinary group — in consultation with the patient’s attending physician (if they have one) — must update the comprehensive assessment no less than every 15 days and include information on the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care.

3. Subpart D — Conditions of participation: Organizational environment

§ 418.100 Condition of participation: Organization and administration of services

• Serving the patient and their family: Your hospice must provide care that optimizes comfort and dignity and is consistent with patient and family needs and goals.
• Governance: Your hospice must appoint a governing body that assumes full legal authority and responsibility for the management of the hospice and its operations. It must also appoint a qualified administrator who is responsible for day-to-day operations.  This administrator must be a hospice employee and possess education and experience designated by the governing body.
• Services: Your hospice must be primarily engaged in providing nursing services, medical social services, physician services, counseling services, hospice aide services, physical therapy, short-term inpatient care, and medical supplies.

§ 418.102 Condition of participation: Medical director

• Medical director contract: Your hospice must appoint a physician to serve as medical director. The medical director must be a doctor of medicine or osteopathy and must be an employee of or be under contract with the hospice. You may contract with either a self-employed physician or a physician employed by a professional entity or physicians group.

§ 418.104 Condition of participation: Clinical records

• Content of clinical records: Patient records must include seven pieces of information, including the initial plan of care, signed copies of the notice of patient rights, responses to medications, outcome measure data elements, physician certification and recertification of terminal illness, any advance directives, and physician orders.
• Record retention: Your hospice must retain patient clinical information for six years after the death or discharge of the patient, unless state law stipulates a longer period of time.

4. Subpart F — Covered services

§ 418.202 Covered services

Covered hospice services, which must be performed by appropriately qualified personnel, include the following:

• Nursing care provided by or under the supervision of a registered nurse
• Medical social services provided by a social worker under the direction of a physician
• Physicians’ services performed by a physician as defined in § 410.20 (Note: A doctor of medicine or osteopathy must perform the services of the hospice medical director or the physician member of the interdisciplinary group.)
• Counseling services provided to the terminally ill patient and the family members or other persons caring for the individual at home
• Short-term inpatient care provided in a participating hospice inpatient unit, or a participating hospital or skilled nursing facility (SNF), that additionally meets the standards in § 418.202 (a) and (e) regarding staffing and patient areas
• Medical appliances and supplies, including drugs and biologicals that are used primarily for pain relief and symptom control related to the patient’s terminal illness
• Home health or hospice aide services furnished by qualified aides as designated in § 418.76 and homemaker services
• Physical therapy, occupational therapy, and speech-language pathology services in addition to the services described in § 409.33 (b) and (c) provided for purposes of symptom control or to enable the patient to maintain activities of daily living and basic functional skills

5. Subpart G — Payment for hospice care

§ 418.301 Basic rules

• Patient charges: Your hospice may not charge a patient for services for which the patient is entitled to have payment made under Medicare or for services for which the patient would be entitled to payment, as described in § 489.21.
• Fundamental payment information: Medicare payment for covered hospice care is made according to payment procedures noted in § 418.302, which includes categories such as routing and continuous home care, inpatient respite care, and general inpatient care.

Jotform Enterprise: A powerful partner for staying compliant with Medicare hospice regulations 

Jotform Enterprise for hospices is an all-encompassing tool that includes form templates, tables, approval workflows, and much more. Compliance is critical in hospice care, and Jotform helps you achieve it through HIPAA-friendly forms for

• Palliative care assessments that collect all the information needed according to Medicare hospice regulations
• Hospice care consent to ensure you have proper record of a patient’s acceptance of care
• Certification of terminal illness to prove the patient qualifies for care and your hospice can submit payment claims

These and other hospice care forms help you comply with the many Medicare hospice regulations that exist, as well as streamline your hospice admissions process for patients and employees alike. Plus, you can easily customize the forms with our no-code builder to suit your hospice’s unique needs.

In addition, hospice administrators can assign custom permissions to different users, ensuring that only the appropriate people see confidential patient information. Start building forms for your hospice business today.

Photo by Jeff Sheldon on Unsplash