NY Manual
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New York Provider Manual
10.7 Routine Vision | 10.9 Transportation

10.8 Hospice – Medicaid, Personal Wellness Plan, CHPlus, Leaf Plans, Commercial, and Medicare

Hospice care requires prior authorization and is covered by Healthfirst for Medicaid, Personal Wellness Plan, CHPlus, Leaf Plans, and Commercial members. Hospice is not covered under our Medicare product offerings. Hospice is a coordinated program that is designed to provide comfort and alleviate the pain of symptoms connected with a terminal illness. This benefit is covered directly by Medicare fee-for-service for Healthfirst Medicare members and must be elected by qualifying individuals. Prior authorization is required from fee-for-service Medicare. Since the hospice benefit is covered directly by Medicare for Healthfirst Medicare members, these members will continue to be covered through Healthfirst for treatment for conditions other than the terminal illness.

The hospice benefit covers provider services; nursing care; pain and symptom management; physical, occupational, and/or speech therapy; home health aide services; homemaker services; counseling; short term inpatient care; and respite care.

Under the Medicare Hospice Benefit, “terminally ill” means that the individual has a medical prognosis of six months or less if the illness runs its normal course. The beneficiary (or his or her representative) must file and sign an election statement with the particular hospice. Additionally, the Social Security Act requires that the individual or representative electing hospice must acknowledge 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 prognosis; and must acknowledge that he/she waives the right to payment of standard Medicare benefits for treatment of the terminal illness and related conditions. If a Healthfirst Medicare member meets the following criteria, he or she should consider electing Medicare’s hospice services:

·     Member must be entitled to Medicare Part A
·     Member must have a terminal illness as certified by their PCP
·     Member must have a life expectancy of less than six (6) months
·     Member must waive the right to receive treatment for the terminal condition from any provider other than the hospice and attending providers

Hospice service for a Healthfirst Medicare member is covered under Original Medicare, not under the Healthfirst Medicare Plan.