Hospice Services

This policy covers hospice services—including routine home care, continuous home care, inpatient respite, and short‑term general inpatient care—for members with a terminal diagnosis and an expected life expectancy of six months or less, such as cancer, ALS, advanced heart or pulmonary disease, dementia, HIV, end‑stage liver or renal failure, stroke, coma, or progressive non‑disease‑specific decline. Coverage requires meeting the policy’s documentation and severity criteria (Criteria I–III) and a signed hospice election, with specific clinical/functional findings (e.g., PPS/KPS scores and ADL dependence for cancer); exclusions and limits apply (e.g., transplant-listed patients and those on dialysis may be ineligible under certain criteria, curative services are generally excluded except select pediatric Medicaid/CHIP cases), only one level of care may be authorized per day, and time limits/ concurrent review govern continuous, respite, and inpatient approvals.