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The following Advisory Opinion is to advise the
reader of the current position of the Kentucky Department of
Insurance ("The Department") on the specified issue. The Advisory
Opinion is not legally binding on either the Department or the
reader
Kentucky Department of
Insurance
Advisory Opinion
98-02
In re: Hospice care coverage under health benefit
plans
RELEVANT FACTS AND STATUTES:
It has come to my attention that there is confusion over hospice
reimbursement under health benefit plans. Therefore, I feel it
necessary to issue this Advisory Opinion. This opinion is advisory
in nature and is intended to inform entities that issue health
benefit plans how the Department views this issue.
House Bill 315 states that, "[a]ll health benefit
plans shall cover hospice care at least equal to the Medicare
benefits." 42 U. S. C. A. 1395d (d)(1) states:
Payment under this part may be made for
hospice care provided with respect to an
individual only during two periods of 90
days
each and an unlimited number of
subsequent periods of 60 days each during
the individual's lifetime and only, with
respect to each such period, if the
individual
makes an election under this paragraph to
receive hospice care under this part
provided by, or under arrangements made
by, a particular hospice program instead
of
certain other benefits under this
subchapter.
THE DEPARTMENT'S POSITION:
This language indicates that there are not limits on hospice
benefits. Also, the annotations support this conclusion. A 1997
amendment to the law substituted the language " and an unlimited
number of subsequent periods of 60 days each" for ", a subsequent
period of 30 days, and a subsequent extension period".
Under Medicare, the initial period of certification
for hospice care is 90 days. After the initial 90-day period, the
person is re-certified as meeting the requirements for hospice care
for an additional 90 days. Thereafter, every 60 days, the individual
is re-certified as being eligible for hospice care. There are an
unlimited number of times a person can get re-certified for a 60-day
period. Based on Medicare law, health benefit plans cannot limit the
number of days a person can receive hospice care.
Furthermore, Title 42 of the Code of Federal
Regulations, Part 418 specifies particular services that must be
covered under hospice benefits. For example, 42 C. F. R. 418.80
-418.88 relate to counseling and physician services. 42 C. F. R.
§§418.90 - 418.100 relate to, among other things, physical therapy
and home health aide services. 42 C. F. R. 418.200- 418.204 relate
to short-term inpatient care and respite care. Pursuant to H. B.
315, these enumerated services must be covered in relation to
hospice services.
Any questions concerning this matter should be
directed to Shaun T. Orme, counsel for the Department (502)
564-6032.
_____________________________________
George Nichols III
Commissioner
Date: 6/12/98
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