QUEST Integration – Hospice Care

Original Effective Date:

08/01/1994

Current Effective Date:

04/01/2015

For a patient to be eligible for hospice benefits, the attending physician must certify in writing that the patient has a life expectancy of six months or less. The hospice will assess the level of care appropriate for the terminally ill patient.

Services must be provided by agencies participating in HMSA’s network of QUEST Integration providers.

Services Covered Under Hospice Care

A patient in a hospice program may receive any of the following services:

• Continuous home care: predominantly nursing care during a crisis period, thereby enabling him or her to remain at home.
• Routine hospice care: care that takes place in the patient’s home or in a hospice care facility. A patient may not receive both continuous home care and routine hospice care concurrently.
• Inpatient respite care: up to five days of inpatient care (to give the primary care-giver a respite).
• General inpatient care: general inpatient care for pain control or management of acute and severe clinical problems that cannot be managed in other settings.

The intent of the hospice benefit is to provide outpatient hospice services in lieu of other plan benefits. The hospice provider agrees to provide respite care and general inpatient care if these services become necessary. If the participating agency does not have an inpatient setting, the agency will make arrangements at a hospital or skilled nursing facility at no additional cost to the patient or HMSA’s QUEST Integration Plan.

Benefit Limitations

Patients age 21 and over: While under hospice care, a patient, age 21 and over, is not eligible for other medical plan benefits for the treatment of the terminal illness, except for physician services. The patient may receive medical benefits to treat an illness or injury unrelated to the terminal illness.

Patients under age 21 may receive medical benefits to treat an illness of injury related or unrelated to the terminal illness.

Revision History