Hospice Care Regulations and Laws

Advancements in medical care have made many once-terminal conditions manageable, eradicated certain diseases, and boosted life expectancies in general. But no one lives forever and there will come a time in everyone's life (unless it's sudden and unexpected) when death is imminent. For individuals who've reached that point in their lives, hospice care can ease their transition by addressing their palliative (pain management), emotional, social, and spiritual needs.

Although hospice care providers have certain medical expertise, the goal is not to extend the life of the patient, but rather to manage pain and help the patient (and their loved ones) gain closure as they prepare for death. Hospice care may be provided at the patient's home or in a designated facility and typically addresses the emotional needs of loved ones and caregivers as well.

This article focuses on the combination of state and federal hospice care regulations and laws meant to ensure a certain standard of care.

Federal Hospice Care Regulations and Medicare Coverage

Parts of the Social Security Act (including 42 U.S.C., Section 1395d, et seq.) address standards for hospice care pertaining to federal entitlement programs, most notably Medicare. The U.S. Code of Federal Regulations (CFR) establishes more detailed Medicare regulations, including rules related to quality reporting requirements and process and appeals for Medicare Part D drug coverage.

In order to participate in the Medicare hospice program, providers must comply with the "conditions of participation." These conditions generally form a baseline for state licensure as well, although some states may have more stringent requirements.

Hospice Care: Conditions of Participation

Federal law defines palliative care as "patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering." Medicare's hospice benefit regulations, therefore, incorporate the following ideals:

• Patients and their family members know of the terminal condition;
• Additional medical treatment and intervention are indicated only on a supportive basis;
• Pain control should be available to patients as needed for the prevention as well as relief of pain;
• Interdisciplinary teamwork is essential in caring for the patient and their family;
• Family members and friends should be active in providing support during the death and bereavement process; and
• Trained volunteers should provide additional support as needed.

The conditions of participation for hospice providers, listed in 42 CFR Part 418, are too numerous to list in their entirety here. The following is just a summary of these conditions:

• During the initial assessment in advance of care, the patient or representative must receive spoken and written notice of their rights and responsibilities.
• The patient has the right to have their property and person treated with respect, to voice grievances regarding treatment or care, and to be free from discrimination or retaliation for exercising their rights.
• Hospice must ensure that all alleged violations involving mistreatment, neglect, or abuse (including injuries of unknown source) are reported immediately and investigated promptly.
• The patient has the right to receive effective pain management, to be involved in developing their hospice care plan, to refuse care or treatment, to choose their attending physician, and to receive information about the services covered (or not covered) by their hospice benefit.
• Hospice registered nurses must complete an initial patient assessment within 48 hours after election of hospice care, followed by a comprehensive assessment by the hospice interdisciplinary group within five calendar days after election of hospice care.
• The comprehensive assessment must include data allowing for the measurement of outcomes, which must be measured and documented on an ongoing basis.

Medicare Hospice Coverage: The Basics

Medicare-covered hospice care is limited to terminally ill patients whose regular doctor and/or hospice doctor certify that they have six months or less to live. Medicare covers two 90-day periods of hospice coverage, followed by unlimited 60-day benefit periods, with access to additional benefit periods as long as the patient is recertified as terminally ill. Patients have the right to change hospice providers once during each benefit period.

Use Medicare's Hospice Compare online tool to find a Medicare-approved hospice provider in your area, compare agencies, file a complaint, or learn more about hospice care.

State Hospice Care Regulations

State hospice care regulations, usually found in administrative codes, address requirements for hospices contracting with state Medicaid programs as well as rules pertaining to patients. For example, Title 40, chapter 30 of the Texas Administrative Code covers eligibility requirements, duration of coverage (election periods), certification of terminal illness, rules for revoking election of hospice care, general contracting requirements, Medicaid hospice claims requirements, and much more.

The Hospice Patients Alliance provides links to state codes pertaining to hospice care regulations. The following is a sample of state hospice regulations.

• California - Hospice must make services available as needed on a 24-hour basis and provide bereavement counseling for immediate family and significant others.
• Illinois - Hospice programs may be licensed as either comprehensive programs or volunteer programs. Patients have the right to be informed about their care and any changes in their prognosis, the right to review their care plan, and the right to privacy.
• Pennsylvania - In order to be eligible, the applicant (patient) must be residing at home or in a skilled nursing facility (not a hospital). In order to enroll as a licensed hospice, the provider must be Medicare certified in addition to meeting the state's definition of a hospice.

Get Legal Help Understanding Hospice Care Regulations and Laws

When a family member or loved one is expected to die within six months, hospice care provides pain management, emotional support, and bereavement services for everyone involved. But this care must follow certain regulations and procedures. If you're in doubt about these rules or have specific concerns, an experienced health care attorney can help you make sense of it all.