130 CMR 437.412 - Electing Hospice Services

(A) Eligibility for Hospice Services.

(1) MassHealth members, including dual-eligible members, but not including those identified in 130 CMR 437.412(A)(2), are eligible for hospice services if

(a) their coverage type as set forth in 130 CMR 450.105: Coverage Types covers hospice services; and

(b) they fulfill the following requirements:

1. are certified as terminally ill in accordance with 130 CMR 437.411;

2. agree to waive certain MassHealth benefits in accordance with 130 CMR 437.412(B); and

3. elect to receive hospice services in accordance with 130 CMR 437.412(C).

(2) MassHealth members younger than 21 years old who have elected the hospice benefit will have coverage for curative treatment and all medically necessary services for which they are eligible. For such members, the hospice provider remains responsible for all hospice services as described in 130 CMR 437.423.

(3) For members enrolled in a MassHealth-contracted managed care organization (MCO) or accountable care organization (ACO) who elect hospice services, the hospice provider must be contracted with the member's ACO/MCO plan, as applicable, and the hospice provider must comply with the ACO/MCO's requirements for the delivery of hospice services.

(B) Waiver of Other Benefits. With the exception of members described in 130 CMR 437.412(A)(2), upon electing to receive hospice services, a member waives all rights to MassHealth coverage for the following services for the duration of the election of hospice services:

(1) hospice services provided by a hospice provider other than the one designated by the member on the hospice election form submitted to the MassHealth agency;

(2) any MassHealth services that are related to the treatment of the terminal illness for which hospice services were elected, not including room and board in a nursing facility or ICF/IID when nursing facility or ICF/IID is otherwise a covered benefit for a member's coverage type (see 130 CMR 437.424(B) and 130 CMR 450.105: Coverage Types'); and

(3) any MassHealth services that are equivalent to or duplicative of hospice services, except for

(a) MassHealth state plan personal care services, including MassHealth Personal Care Attendant (PCA) Program services (130 CMR 422.000) and MassHealth Adult Foster Care/Group Adult Foster care Program services (130 CMR 408.000: Adult Foster Care), as well as MassHealth Home and Community-based Services (HCBS) waiver services that provide assistance with personal care, when used to the extent that the hospice provider would routinely use the services of a member's family in implementing the plan of care. As provided under 130 CMR 437.423(B), PCA, AFC/GAFC, and HCBS waiver services that provide personal care must be coordinated with the provision of hospice services, as well as with any in-home support services that the member is receiving or is eligible to receive, from a home and community-based services network; and

(b) physician services provided by the member's attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.

(C) Hospice Election and Change in Hospice Election. Each time a MassHealth member who meets the requirements of 130 CMR 437.412(A) seeks to elect hospice services, revoke hospice services, or change hospice providers in accordance with 42 CFR 418.24 and 130 CMR 437.412, the hospice provider must notify the MassHealth agency of the member's hospice election or change in hospice election.

(1) Hospice Election Statement. When a member meets the requirements of 130 CMR 437.412(A) and chooses to elect hospice, the hospice provider must have the member or member's representative sign a hospice election statement that meets all requirements of 42 CFR 418.24(b) and (c). The hospice election statement must be specific to MassHealth and the member must be aware that in signing the election statement they are waiving their rights to MassHealth coverage for certain services for the duration of their hospice election. See 130 CMR 437.412(B).

(2) Hospice Revocation. The member or the member's representative may revoke the election of hospice services at any time during the hospice election period. The hospice provider must document the revocation in the member's medical record and notify the MassHealth agency according to 130 CMR 437.412(C). Upon revocation of the election of hospice services for a particular election period, the member:

(a) is no longer covered under MassHealth for hospice services;

(b) resumes MassHealth coverage for the services waived upon election of hospice services; and

(c) may at any time elect to receive hospice services for any remaining hospice election periods for which the member is eligible.

(3) Change in MassHealth Hospice Providers. A member may change hospice providers once in each hospice election period. To change from one hospice provider to another, the new hospice provider must notify the MassHealth agency according to 130 CMR 437.412(C) indicating a change in hospice providers. A member does not revoke election of hospice services by changing their MassHealth hospice provider.

(4) Hospice Disenrollment. The hospice provider must document hospice disenrollment in the member's medical record and include the reason for disenrollment and the effective date of disenrollment.

(5) MassHealth Application Pending. Once an individual's eligibility is approved for a MassHealth coverage type that includes hospice care, MassHealth coverage for hospice services for an individual who meets the requirements of 130 CMR 437.412(A) may be effective only on or after the date the individual signs a hospice election statement that meets the requirements of 130 CMR 437.412(C)(1), regardless of any previous hospice election by the individual for an insurer other than MassHealth, and no earlier than the date the individual's MassHealth eligibility is approved.

(6) Dual-eligible Members. Hospice providers must ensure that dual-eligible members elect and revoke their MassHealth hospice benefit simultaneously with their Medicare hospice benefit.

(7) Notifying the MassHealth Agency of Hospice Election and Change in Hospice Election. A hospice provider must notify the MassHealth agency of a member's hospice election or change in hospice election through the provider portal, or as otherwise instructed by the MassHealth agency within 14 calendar days after the effective date of election.

(8) Exceptions. If a Hospice provider is unable to timely notify the MassHealth agency of a Hospice Election and/or Change in Hospice Election, the hospice provider must fully document and furnish any requested documentation to the MassHealth agency for a determination of exception as soon as possible and no later than 90 days from the date of election. The permissible exceptions are as follows:

(a) fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice provider's ability to operate;

(b) an event that produces a data filing problem due to a MassHealth contractor systems issue that is beyond the control of the hospice provider;

(c) a newly enrolled MassHealth hospice provider that is notified of enrollment after the MassHealth enrollment date, or is awaiting its MassHealth provider ID from MassHealth;

(d) the member's MassHealth eligibility is approved and retroactively applied after the member signs the hospice election form; and

(e) other situations determined by the MassHealth agency to be beyond the control of the hospice.

(D) Effective Date for Hospice Services.

(1) The effective date for hospice election, hospice revocation, or changing hospice providers is the effective date entered by the hospice provider on the hospice election form submitted to the MassHealth agency.

(2) The effective date for hospice services may not be earlier than the date the member or the member's representative signed the hospice election statement.

Notes

130 CMR 437.412

Amended by Mass Register Issue 1353, eff. 12/1/2017. Amended by Mass Register Issue 1485, eff. 1/1/2023.