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TITLE 40SOCIAL SERVICES AND ASSISTANCE
PART 1DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 30MEDICAID HOSPICE PROGRAM
SUBCHAPTER BELIGIBILITY REQUIREMENTS
RULE §30.14Certification of Terminal Illness and Record Maintenance

(a) Timing of certification.

  (1) If a hospice does not obtain the written certification statement required by paragraph (2) of this subsection within two days after a period of care begins, the hospice must obtain an oral certification statement that meets the requirements of this section no later than two days after the period begins. A period of care is described in §30.12 of this subchapter (relating to Duration of Hospice Care Coverage: Election Periods).

  (2) For the initial period of care, a hospice must obtain a signed and dated Medicaid Hospice Program Physician Certification of Terminal Illness form that meets the requirements of this section before the hospice submits an initial request for payment, but no more than 15 days before the period begins. For a period of care after the initial period, a hospice must obtain a signed and dated Medicaid Hospice Program Physician Certification of Terminal Illness form that meets the requirements of this section before the period expires, but no more than 15 days before the period begins.

(b) Content of certification statement. An oral or written certification statement must:

  (1) specify that an individual's prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course;

  (2) include a narrative that clearly identifies the reasons the individual is considered terminally ill; and

  (3) include clinical information that supports the medical prognosis, which may be provided orally for an oral certification statement and must be provided with accompanying documentation for a written certification statement.

(c) Sources of certification. The hospice must obtain a written or oral certification statement required by subsection (a) of this section from:

  (1) for the initial period of care:

    (A) the medical director of the hospice or the physician who is a member of the hospice interdisciplinary group; and

    (B) the individual's attending physician, if the individual has an attending physician; and

  (2) for a period of care after the initial period, a physician described in paragraph (1)(A) of this subsection.

(d) Documentation.

  (1) After the hospice receives a certification statement, hospice staff must:

    (A) for an oral certification statement:

      (i) make an entry that meets the requirements of paragraph (2) of this subsection in the individual's hospice record; and

      (ii) if the individual resides in a nursing facility or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), notify the nursing facility or the ICF/IID of the oral certification; and

    (B) for a written certification statement:

      (i) file the statement and supporting documentation in the individual's hospice record; and

      (ii) if the individual resides in a nursing facility or an ICF/IID, provide the nursing facility or the ICF/IID with a copy of the written certification.

  (2) An entry made in an individual's hospice record in accordance with paragraph (1)(A)(i) of this subsection must include the name of the physician who made the oral certification, the clinical information that supports the prognosis, and the date the hospice received the certification. The hospice staff person who makes the entry into the individual's hospice record must sign and date the entry.

(e) Face-to-face assessment. To determine an individual's continued eligibility for hospice care for a period of care after the initial period, as described in §30.12 of this subchapter, a hospice physician or hospice advanced practice registered nurse must perform a face-to-face assessment of the individual.

  (1) The hospice must ensure a face-to-face assessment is performed before each subsequent period of care begins, but no more than 30 days before the period begins.

  (2) For an individual who is dually eligible for Medicare and Medicaid, a Medicare face-to-face encounter satisfies the requirement for a face-to-face assessment required by this subsection.

(f) Records.

  (1) The hospice must retain in an individual's hospice record documentation to support the services provided by the hospice, including:

    (A) the documentation required by subsection (d) of this section;

    (B) a current Minimum Data Set assessment if the individual resides in a nursing facility, or a level-of-need assessment if the individual resides in an ICF/IID; and

    (C) documentation of a face-to-face assessment or a face-to-face encounter described in subsection (e) of this section.

  (2) If an individual resides in a nursing facility or ICF/IID, the hospice must provide a copy of the documentation described in paragraph (1) of this subsection to the nursing facility or ICF/IID in which the individual resides.


Source Note: The provisions of this §30.14 adopted to be effective March 1, 2001, 26 TexReg 1549; amended to be effective May 1, 2002, 27 TexReg 3585; amended to be effective March 1, 2003, 28 TexReg 1396; amended to be effective September 1, 2008, 33 TexReg 7281; amended to be effective April 29, 2015, 40 TexReg 2284

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