Summary Plan Description

Hospice Care

100% Network and Non-Network
Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

Hospice care refers to palliative care (medical relief of pain and other symptoms) for patients who have been diagnosed as terminally ill and whose life expectancy has been determined to be six months or less. A "hospice program" is defined as a public agency or a private organization that is primarily engaged in providing the care and services described below and that makes these services available as needed, on a 24-hour basis. The hospice program provides care and services in a patient's home and on a short-term inpatient basis. The hospice program can either be a Medicare-certified hospice agency or certified as a hospice care agency by the Washington State Department of Social and Health services or the equivalent department of another state. A provider that is certified for Medicare participation as a hospital, skilled nursing facility, or home health agency may be certified as a hospice.

Benefits are provided for the services and supplies of an approved hospice agency for a maximum of six months as described below.

Covered Charges For Services In the Patient's Home

Home hospice care services are covered if the patient is ill enough for hospitalization. In addition, the patient must be "homebound" meaning the patient cannot leave the home without a considerable and taxing effort and is unable to use public transportation without the assistance of another. Benefits are limited to the following services which must be provided by employees of, and billed by, an approved hospice:

  • Physician services.
  • Nursing services by a registered nurse (RN) or licensed practical nurse (LPN).
  • Physical therapy by a physical therapist.
  • Speech therapy by a speech therapist.
  • Occupational therapy by an occupational therapist.
  • Respiratory therapy by a respiratory therapist.
  • Medical social services by a licensed social worker (MSW) under the direction of a physician.
  • Home health aide services by an aide who is under the supervision of a registered nurse are limited to the following: part-time or intermittent care including ambulation and exercise, personal care essential to achieve the medically desired result, assistance with medications, the reporting of changes in the patient's condition and needs, and completion of appropriate records.
  • Medical supplies dispensed by the hospice that would have been provided on an inpatient basis.
  • Drugs and medicines dispensed by or through the hospice agency that are legally obtainable only with a physician's written prescription or provided on an inpatient basis but only such drugs and medicines which are reasonable and necessary for palliation and management of terminal illness.
  • Respite care meaning continuous care of the patient to provide temporary relief to family members or friends from the duties of caring for the patient.
  • Nutritional guidance by a registered dietitian.

The following limits apply to hospice care received in the patient's home:

  1. Visits of one or more hours in which skilled care is required by a registered nurse (RN), licensed practical nurse (LPN), home health aide, licensed social worker (MSW), or a physical, speech or respiratory therapist are limited to a combined total of 60 visits.
  2. Respite care in which no skilled care is required is limited to a combined total of 120 hours per three-month period.

Covered Charges For Inpatient Hospice Services

Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

When a patient is confined as an inpatient in an approved hospice facility, the same benefits that are available in the patient's home are available to the patient on an inpatient basis. These services must be provided by employees of, and billed by, the approved hospice agency. This inpatient hospice benefit is limited to 14 days during the six-month benefit period.

Benefits are not provided for (in the patient's home or inpatient hospice services):

  1. Services for spiritual counseling.
  2. Services to other family members.
  3. Services provided by volunteers, household members, family, or friends.
  4. Food, clothing, housing, or transportation.
  5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps or support railings.
  6. Homemaker or housekeeping services.
  7. Financial or legal counseling services.
  8. Custodial or maintenance care, except that benefits are provided for palliative care to a terminally ill patient subject to the limits stated.
  9. Services or supplies not included in the written treatment plan or not specifically set forth as a covered benefit.
  10. Private duty nursing.

If, while receiving hospice care, a patient requires treatment for a condition not related to the terminal illness, normal plan benefits apply.