COPS PLANNING FOR SUCCESS MEDICARE HOSPICE CONDITIONS OF PARTICIPATION (COPS) BY TOPIC SERIES

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1 Key pints: COPS PLANNING FOR SUCCESS MEDICARE HOSPICE CONDITIONS OF PARTICIPATION (COPS) BY TOPIC SERIES HOSPICE MULTIPLE LOCATIONS The revised COPS include requirements that must be met in rder fr a hspice t prvide services thrugh a "multiple lcatin." Althugh CMS has prvided guidance t hspice surveyrs regarding apprval f satellite r multiple lcatins as far back as 1997, this is the first time that the guidance has appeared in statutes r regulatins gverning hspices participating in Medicare. If a hspice lcatin is apprved by CMS as a multiple lcatin, the lcatin des nt need a separate Medicare certificatin number (prvider number); rather it can perate under the hspice's existing certificatin number. The COPS state that all hspice multiple lcatins must be apprved by Medicare befre prviding hspice care t Medicare patients. This is separate frm any apprvals prvided by state survey agencies, whether fr state licensure purpses r therwise. The Medicare apprval must be received frm the CMS Reginal Office. An equipment strage site r a site perated fr the cnvenience f staff (such as a site where staff can cmplete paperwrk r check messages) is nt cnsidered a multiple lcatin and des nt require Medicare apprval. (See 73 Fed. Reg (June 5, 2008)). Hwever, state licensure laws may cntain separate requirements fr these lcatins. Multiple Lcatins Cnditin f Participatin A multiple lcatin is defined by the COPS as "a Medicare-apprved lcatin frm which the hspice prvides the same full range f hspice care and services that is required f the hspice issued the certificatin number. A multiple lcatin must meet all f the cnditins f participatin applicable t hspices." (See 42 C.F.R ) A hspice perating a multiple lcatin must meet the fllwing requirements (See 42 C.F.R (f)): Medicare apprval befre prviding hspice care t Medicare patients; The multiple lcatin must be part f the hspice and share administratin, supervisin and services with the hspice issued the certificatin number; Natinal Hspice & Palliative Care Organizatin All rights reserved.

2 The lines f authrity and the prfessinal and administrative cntrl must be clearly delineated in the hspice's rganizatinal structure and in practice, and must be traced t the certified lcatin; and The hspice must cntinually mnitr and manage all services prvided at all f its lcatins t ensure that services are prvided in a safe and effective manner in accrdance with the COPS. CMS Cmmentary n Multiple Lcatins in the COPS The CMS cmmentary t the COPS discusses in mre detail the requirements regarding multiple lcatins: All "cnvenience sites where staff stp in t cmplete paperwrk r check messages, r warehuse sites where equipment is stred" are nt multiple lcatins and d nt require Medicare apprval. (See 73 Fed. Reg (June 5, 2008)). CMS has said it is the level f cntrl and supervisin exerted by the hspice ver the multiple lcatin, and nt mileage limitatins r staffing levels, that determines whether a site is a multiple lcatin r a cmpletely separate hspice lcatin that requires its wn certificatin number. Therefre, CMS gives n guidance n the number f miles that a multiple lcatin may be lcated frm the certified lcatin and still qualify fr apprval. Befre perating a multiple lcatin (a "practice lcatin" accrding t the 855A, the CMS enrllment frm), the hspice must enrll with the fiscal intermediary and ntify the state survey agency and CMS f all currently-apprved multiple lcatins at the time that the hspice requests a new multiple lcatin. If a hspice prvides services ut f an unapprved r disapprved multiple lcatin, CMS states that these services may be determined t be nn-cvered by Medicare. Multiple lcatins are subject t state survey agency r CMS reginal ffice surveys, and a deficiency identified at a multiple lcatin will apply t the entire hspice issued the certificatin number. Factrs that CMS will cnsider when reviewing a request fr a hspice multiple lcatin include, but are nt limited t: The hspice's ability t supervise the multiple lcatin t ensure quality f care; The hspice's past cmpliance histry; Relevant state issues and recmmendatins, such as reciprcal agreements between states t assure that at least ne f the state agencies assumes respnsibility fr necessary surveys f multiple lcatins when a hspice prvides services acrss state lines, certificate f need requirements, state licensure requirements, etc.; and Natinal Hspice & Palliative Care Organizatin All rights reserved.

3 The ability f the hspice t ensure that each patient receives care frm an assigned interdisciplinary grup t identify and meet the needs f the hspice patient and family. In issuing the new COPS, CMS refused t exempt existing hspice multiple lcatins frm btaining Medicare apprval because "hspices have been required thrugh a CMS plicy memrandum frm the Directr f the Office f Chrnic Care and Insurance Plicy and the Deputy Directr fr Survey and Certificatin t all Reginal Administratrs n the subject f the Hspice Cnditins f Participatin (June 27, 1997) t btain Medicare apprval fr multiple lcatins since Thus, there is n need t exclude existing multiple lcatins frm btaining Medicare apprval because they shuld have already received such apprval." (See 73 Fed. Reg (June 5, 2008)). Hspice Prgram Interpretive Guidance - Multiple Lcatins CMS released its mst recent versin (Interim Interpretive Guidelines Versin 1.1) f the Hspice Prgram Interpretive Guidance t the state survey agency directrs n January 2, The interpretive guidelines related t 42 C.F.R (f)(1)(i) cntain the guidance t survey agencies related t Medicare apprval fr multiple lcatins. The guidance states the fllwing: It is lngstanding CMS plicy that there is n basis fr a prvider t bill Medicare fr services prvided frm a hspice lcatin that has nt been determined t meet the hspice COPS. When a hspice wishes t add a multiple lcatin, it must d the fllwing: Ntify, in writing, CMS, the state survey agency and, if deemed, its apprved accreditatin rganizatin f the prpsed lcatin if it expects the lcatin t participate in Medicare r Medicaid; Submit a CMS Frm 855-A change f infrmatin request (including all supprting dcumentatin) t its Medicare Administrative Cntractr (MAC) befre CMS apprval can be granted; and The hspice must btain CMS apprval f the new lcatin befre it is permitted t bill Medicare fr services prvided frm the new lcatin. When CMS receives the request fr a multiple lcatin, it must carefully evaluate the infrmatin and any supprting dcumentatin. If a decisin can be made based n the written applicatin and supprting dcumentatin, CMS will grant r deny apprval withut a survey. If circumstances warrant a survey, CMS will s advise the hspice and make n further findings until a Medicare certificatin survey has been cmpleted and submitted t CMS fr review. CMS will ntify the hspice f its decisin, but there are n specified time frames fr CMS t take actin. CMS will nt apprve a hspice's inpatient facility r a change f lcatin fr a hspice's inpatient facility withut a survey t assure that the facility meets all requirements in 42 C.F.R A hspice may nt bill Medicare fr services prvided frm a multiple lcatin until the new site r lcatin has been apprved by CMS. The fact that an Natinal Hspice & Palliative Care Organizatin All rights reserved.

4 accreditatin rganizatin with deeming authrity has apprved a new site r lcatin will nt affect CMS' decisin, which will be based n an independent applicatin f the regulatins. Services prvided befre the effective date f apprval shuld nt be billed t Medicare. Suggestins fr hspice multiple lcatins NHPCO guidance t hspices with respect t multiple lcatins: Befre deciding t pen a hspice multiple lcatin t prvide the full range f hspice care and services prvided by the main lcatin, review the available guidance frm CMS n the requirements fr a multiple lcatin t ensure that the lcatin can qualify as a multiple lcatin. If the lcatin des nt qualify, the hspice shuld enrll the lcatin as a new prvider in the Medicare prgram and btain a separate certificatin number fr the lcatin. As sn as pssible after deciding t pen a multiple lcatin, cntact (1) the hspice's state hspice licensure agency; (2) the hspice's state survey agency (if different than the licensure agency); (3) the CMS reginal ffice respnsible fr the hspice's state; (4) the hspice's accreditatin agency, if any, and: (5) the hspice s fiscal intermediary ( FI ) r Medicare Administrative Cntractr ( MAC ) The cmmunicatin shuld be in writing and dated, and shuld include adequate infrmatin t allw each agency t determine that the multiple lcatin can apprpriately meet the requirements f a multiple lcatin as described in this tip sheet and ther CMS guidance. Keep cpies f all cmmunicatins t r frm these agencies. Until CMS apprval is btained, d nt prvide hspice services ut f the multiple lcatin. Befre such apprval is granted, a hspice may chse t utilize the lcatin as a cnvenience site r drp-ff site fr staff, if all necessary state apprvals are btained. Hwever, prviding any direct patient care activities (such as running IDG meetings) frm the lcatin may put the hspice at risk f a CMS determinatin that unapprved services were prvided frm the lcatin. If the prpsed multiple lcatin is in a state ther than where the hspice's certified lcatin is fund, refer t NHPCO's tip sheet n prviding hspice services acrss state lines. If a hspice is currently perating a multiple lcatin that has nt been apprved by CMS, cntact NHPCO as sn as pssible. In sme cases, state survey Natinal Hspice & Palliative Care Organizatin All rights reserved.

5 agencies r state licensure agencies may have given hspices incnsistent guidance regarding multiple lcatins. Resurces fr success! NHPCO s Regulatry & Cmpliance Center CP s Planning fr Success campaign Please nte that hspice prviders need t cmply with the mst stringent regulatry requirements. (Federal r State) Natinal Hspice & Palliative Care Organizatin All rights reserved.