These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is required for the following:
- Respite care
- Continuous care
- Inpatient Services related to Acute Symptom Management of Terminal Illness
Prior notification is required for home visits (0-2 hours) related to hospice treatment while members are enrolled in hospice.
Prior authorization is not required for the following:
- Medically necessary Durable Medical Equipment (DME),
- Formula or supplements such as Ensure when it is the sole source of nutrition
- Disposable supplies
- Office visits
Hospice is generally covered subject to the indications listed below and per your plan documents.
To be eligible for hospice members must:
- Be terminally ill (life expectancy of six months or less), and
- Have chosen a plan of care focused on comfort and supportive service (palliative) and not curative care, and
- Elect to receive services primarily in the home, and
- Be accepted by a hospice program as a participant and have signed the hospice election form.
- Providers must be Medicare certified.
- Care must be provided in accordance with an approved hospice treatment plan as directed by the attending physician.
- Medically necessary part-time care (the visit is 0 to 2 hours) that is provided in the member's home by an interdisciplinary hospice team, which may include a physician, nurse, social worker, PT, OT or speech therapist, home health aide or spiritual counselor.
- Continuous Care (more than 2 hours per day) is generally limited to 2-12 hours per day. Respite Care is generally limited to 5 days per episode. Combined coverage is generally limited to 30 days.
- Inpatient services for acute care when authorized by the HealthPartners Medical Director or his or her designee:
- In patient care for an acute condition not related to the terminal illness is generally covered under the medical benefit.
- In patient care for acute symptom management (e.g., medication titration) related to the terminal condition is generally covered under the hospice benefit.
- Residential hospice care unless member contract specifies differently
- Room and board are not covered if the patient resides in a nursing home or hospice residential facility
- Financial or legal counseling services
- Housekeeping or meal services in the patient's home
- Custodial care related to hospice services, whether provided in the home or in a nursing home
- Any services not specifically described as a covered service under the home hospice services benefit (such as Music Therapy, Massage Therapy, Bereavement Counseling)
- Any services provided by members of the patient's family or residents in the member's home
- Costs related to Inpatient confinement when care rendered by the facility is custodial
- Duplicate services
Continuous care - Hospice care provided by a registered nurse, licensed practical nurse, or home health aide during a period of crisis in order to maintain a terminally ill patient at home.
Custodial Care - This is supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to, bathing, dressing and feeding. Care furnished to an individual who has elected the hospice care option is custodial only if it is not reasonable and necessary for the palliation or management of the terminal illness or related conditions.
Hospice - Hospice refers to a concept of compassionate and palliative care for people in the final phase of an incurable illness. Hospice seeks neither to hasten nor postpone death. The emphasis is on quality of life by recognizing physical needs (pain control) as well as social, emotional and spiritual needs. Members may withdraw from the Hospice program at any time. HealthPartners staff documents enrollment and disenrollment dates for administering hospice benefits.
Respite care - Care in the person’s home or appropriate facility rendered to give the patient’s primary caregivers (I.e., family members or friends) rest/or relief when necessary in order to maintain a terminally ill patient at home.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.