Clinical UM Guideline

This document addresses home hospice care. Home hospice care refers to a comprehensive home-based, interdisciplinary care program for individuals with a serious medical illness and a prognosis of 6 months or less if the disease follows its natural course.

Note: Please see the following related documents for additional information:

• CG-MED-23 Home Health
• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 Private Duty Nursing in the Home Setting
• CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

Note: The Clinical Indications in this document apply to hospice care delivered in the home setting only.

Medically Necessary:

Home hospice services are considered medically necessary when both of the following criteria (A and B) below are met:

1. The individual requires hospice care, as evidenced by meeting both of the following criteria (1 and 2):
   1. The individual is terminally ill (for example, life expectancy is 6 months or less if illness runs its normal course); and
   2. The individual requires services for the management of a terminal illness and related condition(s).
      and
2. The individual requires either of the following:
   1. Routine home hospice services: Services required for less than 8 hours of predominantly nursing care during a 24-hour day, which begins and ends at midnight; or
   2. Continuous home care services: Services required when both of the following criteria (a and b) are met:
      1. The individual requires a minimum of 8 hours of nursing, hospice aide, or homemaker care during a 24-hour day*, which begins and ends at midnight.
         and
      2. The continuous home care services are provided only during a period of crisis** as necessary to maintain an individual at home.

*This care does not need to be uninterrupted, e.g., 4 hours could be in the morning and another 4 hours in the evening. In addition to the 8-hour minimum, the services provided must be predominantly nursing care, provided by either a registered nurse (RN), a licensed practical nurse (LPN), or a licensed vocational nurse (LVN).

**A period of crisis is a period in which an individual requires hospice care to achieve palliation or management of acute medical symptoms. If an individual’s caregiver has been providing a skilled level of care for the individual and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.

Not Medically Necessary:

Home hospice services are considered not medically necessary when the medically necessary criteria above have not been met.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Hospice Care Services

Hospice care services are generally provided when an individual is estimated to have 6 months or less to live. According to the American Cancer Society (ACS), hospice services provide individuals with comfort and support care during the last phases of an incurable disease so that they may live as fully and comfortably as possible. In their review of comprehensive hospice care, Fine and colleagues (2006) point out that the focus of hospice treatment is palliative, not curative, and that “hospice care is based on a biopsychosocial model rather than a disease model of care”. With the understanding that death is an inevitable result of living, hospice care emphasizes “quality of life at the end of life and supportive care rather than a cure or life prolongation”.

According to the National Institute on Aging (NIA):

Hospice care is a service for people with serious illnesses who choose not to get (or continue) treatment to cure or control their illness. … Hospice aims to provide comfort and peace to help improve quality of life for the person nearing death. It also helps family members cope with their loved one’s illness and can also provide support to the family after the person dies, including help with grieving, sometimes called bereavement care …

Many people with a serious illness use hospice care. A serious illness may be defined as a disease or condition with a high risk of death or one that negatively affects a person’s quality of life or ability to perform daily tasks. It may cause symptoms or have treatments that affect daily life and lead to caregiver stress. Examples of serious illnesses include dementia, cancer, heart failure, and chronic obstructive lung disease (NIA, 2021).

According to Meier (2023), hospice programs generally consider the individual and the individual’s family or loved ones as the recipients of care. Hospice care services can be provided to individuals of all ages and generally involve an interdisciplinary team. The hospice interdisciplinary team consists of specially trained clinicians and support staff whose goals are to ensure that the individual and their families or loved ones are provided holistic care. The interdisciplinary team may include any of the following:

• Registered hospice nurse who is responsible for skilled nursing care and the coordination of other members of the interdisciplinary hospice team.
• Hospice physician who fulfills a medical and administrative role and is often board-certified in the specialty of palliative and hospice medicine. The hospice physician may also act as a liaison to the attending clinicians and assists with the management of the individual’s symptoms.
• Primary attending physician (as well as the referring physician) who helps guide the individual’s care after the referral to hospice care is made.
• Social worker who provides psychosocial (e.g., nutrition, transportation, housing and family caregiver) support for the individual and the individual’s families and loved ones. This support may also include counseling, anticipatory grief, bereavement, burial/funeral planning and referrals to other support systems.
• Chaplain may oversee the spiritual needs of the individual and the individual’s families and loved ones.
• Home health aides and other direct care workers may provide assistance to the individual and the individual’s caregivers in the home, including food preparation, shopping and personal care.
• Bereavement counselors may provide support to the bereaved family members and loved ones of the hospice individual.
• Community volunteers may provide extra support for the individuals and families and loved ones of the individuals, providing services such as reading to and visiting with the individual, as well as assisting with errands.

Levels of Hospice Care

The Centers for Medicare and Medicaid Services’ (CMS) Medicare Benefit Policy Manual Chapter 9 Coverage of Hospice Services Under Hospital Insurance has designated four levels of hospice care, each focusing on the specific needs of the person receiving care:

• Routine Home Care (RHC) is the most common level of hospice care. With this type of care, an individual has chosen to receive hospice care at their residence. The individual is stable, can control their symptoms and do not require continuous or inpatient hospice care.
• Continuous Home Care (CHC) is hospice care that is provided for between eight and 24 hours a day in order to manage acute medical symptoms and pain. CHC services consist primarily of nursing care, supplemented with caregiver and/or hospice aide services with the goal of maintaining the terminally ill individual at home during a pain or symptom crisis.
• Inpatient Respite Care (IRC, also referred to as Respite Care) is available to provide temporary relief to the individual’s primary caregiver. Respite care may be provided in a hospital, hospice facility, or a long-term care facility with enough 24-hour nursing personnel present.
• General Inpatient Care (GIP) is provided to cover all aspects of the individual’s care related to the terminal illness, including all services delivered by the interdisciplinary hospice team, medication, supplies and medical equipment. This includes care that is provided for acute symptom or pain management that cannot plausibly be provided in another setting. GIP may be provided in a hospice inpatient facility, Medicare certified hospital, or nursing facility with a registered nursing staff available 24 hours a day to provide direct patient care (CMS, 2024; NHPCO, 2024).

Location of Hospice Care

Most often hospice care is provided in the place the individual receiving hospice care considers home. In addition to private residences, hospice care may be provided in nursing homes, assisted living facilities, and residential facilities. Hospice care may also be provided in freestanding hospice facilities and hospitals. The Clinical Indications in this document apply only to hospice care delivered in the home setting.

Home Hospice Care

The National Association for Home Care & Hospice, and the National Alliance for Care at Home encourages hospice providers to “promote inclusivity in the community by ensuring all people regardless of race, ethnicity, color, religion, gender, disability, sexual orientation, age, disease, or other characteristics have access to high-quality, end-of-life care”.

In spite of the increased utilization of hospice services in recent decades, racial disparities in the use of hospice care services have been identified. In a population-based cohort study, Ornstein and colleagues (2020) used Medicare claims data to examine the utilization of hospice care amongst individuals who expired between January 1, 2013, and December 31, 2015, due to natural causes and excluding sudden death. Multivariable logistic regression models were used to explore racial and regional differences in end-of-life outcomes and in stroke mortality. The researchers found that amongst the 1212 fee-for service Medicare beneficiaries who utilized hospice care 3 or more days during the last 6 months of life, 34.9% of black individuals used hospice care compared to 46.2% by white individuals. After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among individuals who died of cardiovascular disease but not among individuals who died of cancer. In analyses adjusted for cause of death (dementia, cardiovascular disease, cancer, and other) and clinical and demographic variables, black individuals were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with white individuals. The study also demonstrated that individuals without cancer were far less likely to use hospice care compared to individuals with a cancer-related cause of death. The authors concluded that in spite of the increased use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. The authors concluded that:

Reducing the stigma of hospice use through education and community outreach is critical. In particular, reducing disparities in hospice use in populations with noncancer causes of death will require improved prognostication, better patient-clinician communication, and rethinking current hospice outreach and enrollment practices (Ornstein, 2020).

Peer Reviewed Publications:

1. Fine PG, Davis D. Hospice: Comprehensive care at the end of life. Anesthesiology Clin N Am. 2006; 24(1):181-204.
2. Ornstein KA, Roth DL, Huang J, et al. Evaluation of racial disparities in hospice use and end-of-life treatment intensity in the REGARDS Cohort. JAMA Netw Open. 2020; 3(8):e2014639.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 9 - Coverage of hospice services under hospital insurance. Rev.12696, Issue date 06-25-24. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf. Accessed on December 26, 2024.
2. Meier DE, McCormick E, Lagman RL. UpToDate. Hospice: Philosophy of care and appropriate utilization in the United States. Available at: https://www.uptodate.com/contents/hospice-philosophy-of-care-and-appropriate-utilization-in-the-united-states/print. Accessed on December 26, 2024.
3. National Hospice and Palliative Care Organization (NHPCO). NHPCO facts and figures (2024). Available at: https://www.nhpco.org/wp-content/uploads/NHPCO-Facts-Figures-2024.pdf. Accessed on December 26, 2024.
4. National Institute on Aging (NIA). Frequently asked questions about hospice care. Reviewed February 8, 2021. Available at: https://www.nia.nih.gov/health/hospice-and-palliative-care/frequently-asked-questions-about-hospice-care. Accessed on December 26, 2024. 
5. NCCN Clinical Practice Guidelines in Oncology™ ^© 2025. National Comprehensive Cancer Network, Inc. Palliative care V1.2025. Revised February 19, 2024. For additional information visit the NCCN website: http://www.nccn.org/. Accessed on January 17, 2025.

1. American Cancer Society. What is hospice care? Last revised May 31, 2024. Available at: https://www.cancer.org/cancer/end-of-life-care/hospice-care/what-is-hospice-care.html#:~:text=Hospice%20care%20can%20be%20started,to%20know%20all%20your%20options. Accessed on December 26, 2024. 

Home Hospice

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