Hospice: Procedural Requirements

01. Physician Certification. The hospice must obtain certification of a participant’s terminal illness as follows: (7-1-26) a. For any period of coverage, the provider must obtain, no later than two (2) calendar days after initiating care, written certification statements signed by the hospice medical director or a physician member of a hospice interdisciplinary group and the participant’s attending physician, when applicable. Certification must verify a participant’s life expectancy is six (6) months or less. If a participant’s medical prognosis or the appropriateness of hospice care is questionable, the Department can obtain another physician’s opinion to verify a participant’s medical status. (7-1-26) b. Maintain monthly certification statements for review. (7-1-26) c. Notify Medicaid when a participant’s designated attending physician is not a hospice employee. (7-1-26) 02. Election Procedures. A participant or their representative must request hospice care by submitting an election statement to a hospice of their choice. (7-1-26) a. Elections for hospice care are effective through any subsequent election periods without a break in care when a participant does not change providers or revoke an election. (7-1-26) b. A participant who elects less than eight (8) monthly election periods within a benefit period may request additional election periods available when they meet the following conditions: (7-1-26) i. Available hospice days did not exceed two hundred ten (210) days in a benefit period due to loss of financial eligibility; (7-1-26) ii. Hospices were not changed excessively; and (7-1-26) iii. More than eight (8) election periods were not revoked. (7-1-26) c. A participant cannot request an effective date earlier than the date of their election. (7-1-26) d. A participant twenty-one (21) years of age or older must waive all rights to Medicaid payments for the duration of an election period of hospice care for services related to their terminal condition except when provided under hospice services. (7-1-26) 03. Hospice Election. Participant statements must identify their choice of hospice provider and an effective date, acknowledge their informed choice of hospice care and waiver of any non-excepted Medicaid services during hospice benefit periods, and be signed and dated by the participant or their representative. (7-1-26) 04. Election Revocation. Participants or their representatives may revoke an election at any time by filing a signed statement with the hospice that includes their request to revoke an election of hospice care and an effective date. Medicaid coverage is reinstated upon revocation. (7-1-26) 05. Hospice Change. Participants may request a change of provider during any eligible election period, but no more than six (6) times during a benefit period. Participants must submit a signed and dated statement to the current provider and the new provider during the monthly election period, that includes the current hospice care provider, new hospice provider requested, and effective date. Changes in provider ownership do not apply. (7-1-26) 06. Plan of Care. Must be established and reviewed at least monthly and include all covered services and supplies. The basic interdisciplinary group member assessing a patient’s needs must confer with at least one (1) other member before writing an initial plan of care. At least one (1) person involved in developing an initial plan must be an RN or physician. Plans must be established on the same day as an assessment to be covered as part of hospice IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 655 Page 159 care. The other two (2) basic interdisciplinary group members must review an initial care plan and provide input to the process of establishing the plan within two (2) calendar days following the assessment. (7-1-26)