SECTION 266.209. Requirements for Payments

To be eligible for Medicaid hospice payment, the hospice must document that services provided meet the following requirements.

(1) The hospice providing the services must have a Medicaid hospice contract with HHSC on the date it provides services.

(2) The services must be reasonable and necessary for the palliation or management of the terminal illness, as well as conditions related to the terminal illness.

(3) The hospice must deliver the services on or after the date the individual elects hospice care in accordance with §266.205 of this subchapter (relating to Election of Hospice Care) but before the date the individual revokes the election of hospice care in accordance with §266.207 of this subchapter (relating to Revoking the Election of Hospice Care).

(4) The hospice election statement must identify the hospice requesting payment as the individual's hospice provider.

(5) A physician must certify that the individual receiving hospice services is terminally ill in accordance with §266.203 of this subchapter (relating to Certification of Terminal Illness).

(6) The individual receiving services must be eligible for Medicaid.

(7) The hospice must establish an individualized plan of care prior to initiating services.

(8) The services the hospice provides must be consistent with the plan of care.

(9) If the individual receiving services lives in a nursing facility or ICF/IID, the hospice must have a contract with that nursing facility or ICF/IID.

(10) If the individual receiving services is dually eligible for Medicare and Medicaid, the hospice service must not be covered by the Medicare hospice benefit.

(11) The hospice must submit both the Individual Election/Cancellation/Update Form and the Physician Certification of Terminal Illness Form to the TMHP Long Term Care Online Portal.

Source Note: The provisions of this §266.209 adopted to be effective July 26, 2022, 47 TexReg 4331