MLTC Policy 13.18

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.18: MLTC Guidance on Hospice Coverage

Date of Issuance: June 25, 2013


The purpose of this policy is to clarify for Managed Long Term Care (MLTC) plans coverage of, and billing for, hospice services provided to existing MLTC enrollees in accordance with recent changes made to Section 4403-f of Article 44 of the Public Health Law. Any MLTC enrollee who requires and meets eligibility requirements for hospice service may elect the Hospice benefit without disenrolling from MLTC.

Individuals currently enrolled in hospice continue to be excluded from subsequently enrolling in MLTC.

MLTC enrollees,with the exception of PACE, are eligible for hospice services when certified by a physician to be terminally ill with a life expectancy of 6 months or less if the disease runs its normal course. The enrollee is entitled to the hospice benefit as long as the enrollee meets eligibility requirements for hospice services.

For MLTC enrollees [Partial MLTC plans and Medicaid Advantage Plus(MAP)], Hospice services are not included in the managed long term care plan benefit, and are billable directly to Medicare and Medicaid as appropriate. This includes hospice services provided in the enrollee´s home (including hospice residence or nursing home) or hospital setting. MLTCs are responsible for any care provided in the home that is unrelated to the enrollee´s terminal illness. MLTCs should coordinate with Hospices to provide care to their enrollees to support the enrollees needs.

Pursuant to federal PACE regulations at 42 CFR Part 460.154(i), PACE enrollees who elect enrollment in the hospice benefit are considered to be voluntarily disenrolled from PACE.