28 CA ADC § 1300.68.2
28 CCR s 1300.68.2
Cal. Admin. Code tit. 28, s 1300.68.2
CALIFORNIA CODE OF REGULATIONS
TITLE 28. MANAGED HEALTH CARE
DIVISION 1. THE DEPARTMENT OF MANAGED HEALTH CARE
CHAPTER 2. HEALTH CARE SERVICE PLANS
ARTICLE 8. SELF-POLICING PROCEDURES
This database is current through 06/09/06, Register 2006, No. 23.
s 1300.68.2. Hospice Services.
(a) For purposes of this section, the following definitions shall apply:
(1) "Bereavement services" means those services available to the surviving
family members for a period of at least one year after the death of the
enrollee. These services shall include an assessment of the needs of the
bereaved family and the development of a care plan that meets these needs,
both prior to, and following the death of the enrollee.
(2) "Hospice service" or "hospice program" means a specialized form of
interdisciplinary health care that is designed to provide palliative care,
alleviate the physical, emotional, social and spiritual discomforts of an
enrollee who is experiencing the last phases of life due to the existence
of a terminal disease, to provide supportive care to the primary care
giver and the family of the hospice patient, and which meets all of the
following criteria;
(A) Considers the enrollee and the enrollee's family, in addition to the
enrollee, as the unit of care.
(B) Utilizes an interdisciplinary team to assess the physical, medical,
psychological, social and spiritual needs of the enrollee and the
enrollee's family.
(C) Requires the interdisciplinary team to develop an overall plan of care
and to provide coordinated care which emphasizes supportive services,
including, but not limited to, home care, pain control, and short-term
inpatient services. Short-term inpatient services are intended to ensure
both continuity of care and appropriateness of services for those
enrollees who cannot be managed at home because of acute complications or
the temporary absence of a capable primary caregiver.
(D) Provides for the palliative medical treatment of pain and other
symptoms associated with a terminal disease, but does not provide for
efforts to cure the disease.
(E) Provides for bereavement services following the enrollee's death to
assist the family to cope with social and emotional needs associated with
the death of the enrollee.
(F) Actively utilizes volunteers in the delivery of hospice services.
(G) To the extent appropriate based on the medical needs of the enrollee,
provides services in the enrollee's home or primary place of residence.
(3) "Hospice" or "Hospice Agency" means an entity which provides hospice
services to terminally ill persons and holds a license, currently in
effect, as a hospice pursuant to Health and Safety Code section 1747 or a
home health agency with federal medicare certification pursuant to Health
and Safety Code sections 1726 and 1747.1.
(4) "Home health aide services" means those services providing for the
personal care of the terminally ill patient and the performance of related
tasks in the patient's home in accordance with the plan of care in order
to increase the level of comfort and to maintain personal hygiene and a
safe, healthy environment for the patient. Home health aide services shall
be provided by a person who is certified by the state Department of Health
Services as a home health aide pursuant to Chapter 8 of Division 2
(Section 1725 et seq.) of the Health and Safety Code.
(5) "Homemaker services" means services that assist in the maintenance of
a safe and healthy environment and services to enable the enrollee to
carry out the treatment plan.
(6) "Interdisciplinary team" means the hospice care team that includes,
but is not limited to, the enrollee and the patient's family, a physician
and surgeon, a registered nurse, a social worker, a volunteer, and a
spiritual caregiver.
(7) "Medical direction" means those services provided by a licensed
physician and surgeon who is charged with the responsibility of acting as
a consultant to the interdisciplinary team, a consultant to the enrollee's
attending physician and surgeon, as requested, with regard to pain and
symptom management, and liaison with physicians and surgeons in the
community. For purposes of this section, the person providing these
services shall be referred to as the "medical director."
(8) "Plan of care" means a written plan developed by the attending
physician and surgeon, the medical director or physician and surgeon
designee, and the interdisciplinary team that addresses the needs of an
enrollee and family admitted to the hospice program. The hospice shall
retain overall responsibility for the development and maintenance of the
plan of care and quality of services delivered. However, nothing in this
section shall be construed to limit a health care service plan's
obligations with respect to its QA program as required under Section
1300.70.
(9) "Skilled nursing services" means nursing services provided by or under
the supervision of a registered nurse under a plan of care developed by
the interdisciplinary team and the enrollee's physician and surgeon to an
enrollee and his or her family that pertain to the palliative, supportive
services required by an enrollee with a terminal illness. Skilled nursing
services include, but are not limited to, enrollee assessment, evaluation
and case management of the medical nursing needs of the enrollee, the
performance of prescribed medical treatment for pain and symptom control,
the provision of emotional support to both the enrollee and his or her
family, and the instruction of caregivers in providing personal care to
the enrollee. Skilled nursing services shall provide for the continuity of
services for the enrollee and his or her family. Skilled nursing service
shall be available on a 24-hour on-call basis.
(10) "Social service/counseling services" means those counseling and
spiritual services that assist the enrollee and his or her family to
minimize stresses and problems that arise from social, economic,
psychological, or spiritual needs by utilizing appropriate community
resources, and maximize positive aspects and opportunities for growth.
(11) "Terminal disease" or "terminal illness" means a medical condition
resulting in a prognosis of life of one year or less, if the disease
follows its natural course. This definition is not intended to limit the
ability of health plans and hospices to develop and utilize comprehensive,
evidence-based medical and psychosocial criteria or "best practice"
guidelines for hospice referrals that are not dependent upon an estimated
time of death, that are predictive of the need and appropriateness of
palliative care and that are consistent with standards among palliative
care professionals.
(12) "Volunteer services" means those service provided by trained hospice
volunteers who have agreed to provide service under the direction of a
hospice staff member who has been designated by the hospice to provide
direction to hospice volunteers. Hospice volunteers may be used to provide
support and companionship to the enrollee and his or her family during the
remaining days of the enrollee's life and to the surviving family
following the enrollee's death.
(b) Hospice services provided pursuant to the requirements of Section
1368.2 shall comply with the following requirements:
(1) Only an entity licensed pursuant to the California Hospice Licensure
Act of 1990, (Health and Safety Code Section 1745, et seq.) or a licensed
home health agency with federal medicare certification (Health and Safety
Code sections 1726 and 1747.1) may provide hospice services to plan
enrollees, except that an entity licensed as a hospice may arrange to
provide hospice services required to be provided pursuant to this section
with appropriately licensed individuals or entities.
(2) Plans are required to provide to enrollees with a "terminal illness",
through their contractual arrangements with hospices, the following
services, at a minimum, when the enrollee qualifies for and chooses
hospice care:
(A) Interdisciplinary team care with development and maintenance of an
appropriate plan of care.
(B) Skilled nursing services, certified home health aide services and
homemaker services under the supervision of a qualified registered nurse.
(C) Bereavement Services.
(D) Social services/counseling services with medical social services
provided by a qualified social worker. Dietary counseling, by a qualified
provider, shall also be provided when needed.
(E) Medical direction with the medical director being also responsible for
meeting the general medical needs of the enrollees to the extent that
these needs are not met by the attending physician.
(F) Volunteer services.
(G) Short-term inpatient care arrangements.
(H) The following shall be provided to the extent reasonable and necessary
for the palliation and management of terminal illness and related
conditions: pharmaceuticals, medical equipment and supplies.
(I) Physical therapy, occupational therapy, and speech-language pathology
services for purposes of symptom control, or to enable the enrollee to
maintain activities of daily living and basic functional skills.
(c) Covered services are to be made available on a 24 hour basis to the
extent necessary to meet the needs of individuals for care that is
reasonable and necessary for the palliation and management of terminal
illness and related conditions.
(d) Special Coverage Requirements.
(1) Periods of Crisis:
Nursing care services must be covered on a continuous basis for as much as
24 hours a day during periods of crisis as necessary to maintain an
enrollee at home. Hospitalization must be covered pursuant to
1300.68.2(b)(2)(G), when the interdisciplinary team makes the
determination that inpatient skilled nursing care is required at a level
that cannot be provided in the home. Either homemaker or home health aide
services or both may be covered on a 24 hour continuous basis during
periods of crisis but the care provided during these periods must be
predominantly nursing care. A period of crisis is a period in which the
enrollee requires continuous care to achieve palliation or management of
acute medical symptoms.
(2) Respite Care:
Respite care is short-term inpatient care provided to the enrollee only
when necessary to relieve the family members or other persons caring for
the enrollee. Coverage of respite care may be limited to an occasional
basis and to no more than five consecutive days at a time.
(e) Every plan shall include notice of the coverage specified in
subdivisions (b), (c) and (d) in the plan's evidence of coverage and
disclosure form on or after January 1, 2002.
(f) All contracts between plans and hospices must be in accordance with
all federal and state hospice licensure requirements.
Note: Authority cited: Section 1344, Health and Safety Code. Reference
cited: Section 1368.2, Health and Safety Code.
HISTORY
1. New section filed 6-26-2001; operative 7-26-2001 (Register 2001, No.
26).
28 CA ADC s 1300.68.2
END OF DOCUMENT
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