Hospice Eligibility, Election, Transfer, Revocation, and Discharge

Hospice Eligibility, Election, Transfer, Revocation, and Discharge A. A beneficiary must meet eligibility requirements for hospice care services. For the duration of an election of hospice care services, a beneficiary waives all rights to Medicaid State Plan services for treatment related to the terminal illness and related conditions. In order to be eligible to elect hospice care services under Medicaid, a beneficiary must: 1. Be Medicaid eligible for full benefits, 2. Be certified by a physician as terminally ill in compliance with 42 C.F.R. § 418.22, 3. Require medically necessary treatment for the palliation and management of a terminal illness and related conditions, 4. The beneficiary or legal guardian/representative must elect hospice care in accordance with 42 C.F.R. § 418.24. B. A beneficiary that meets hospice care eligibility requirements, and chooses the Medicaid hospice benefit must file an election statement with a Mississippi Medicaid enrolled hospice provider. For dual eligible beneficiaries, refer to Rule 1.10. C. The Medicaid enrolled hospice provider must submit the following to the Utilization Management / Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity within five (5) calendar days of a beneficiary’s admission to hospice which includes the following: 1. The beneficiary’s election statement, which includes the following: a) Identification of the particular hospice that will provide care to the beneficiary, b) The beneficiary’s acknowledgment or legal guardian's/representative’s acknowledgment, if applicable, that the beneficiary has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment, c) The beneficiary’s acknowledgement or legal guardian's/representative’s acknowledgment, if applicable, that the beneficiary understands that certain Medicaid State Plan services are waived by the election of hospice, d) An effective date of the election period which cannot be earlier than the date of the election statement, e) The name of the beneficiary's attending physician, if any, along with the following information including, but not limited to, the attending physician's: 1) Full name, 2) Office address, 3) National Provider Identification (NPI) number, and 4) Other detailed identifying information. f) The beneficiary's acknowledgement or legal guardian's/representative's acknowledgment, if applicable, that the designated attending physician is the beneficiary's or legal guardian's/representative's choice. g) The signature of the beneficiary or signature of the legal guardian/representative, if applicable, and date signed. 2. Prior authorization requests must include the following for the initial ninety (90) day election period: a) Signed notice of election form, b) Signed Physician Certification/Recertification of Terminal Illness Form, c) Clinical/medical information supporting terminal prognosis, d) Physician orders, e) Current medication list, and f) Hospice provider plan of care. D. The Medicaid hospice provider must submit prior authorization for any subsequent ninety (90) day election period and subsequent sixty (60) day hospice election periods five (5) calendar days prior to the end of the current election period. 1. The following prior authorization documentation is required: a) Signed Physician Certification/Recertification of Terminal Illness Form (DOM 1165 C), b) Updated clinical/medical information supporting terminal prognosis, c) Updated physician orders, d) Updated medication record, e) Updated plan of care, f) Beneficiary's current weight, vital sign ranges, lab tests, and g) Any other documentation supporting continuation of hospice services. 2. An election to receive hospice care services is considered to continue through the initial election period and through subsequent election periods without a break in service as long as the beneficiary: a) Remains in the care of a hospice, b) Does not revoke the election, c) Is not discharged from the hospice, and d) Continues to meet Medicaid eligibility requirements. E. Additional documentation that is requested by the UM/QIO that is not received within the time period outlined in the Notice of Pending or Suspended Review will result in the effective date beginning when completed required documentation is received. 1. The Division of Medicaid may waive the consequences of failure to submit timely documentation for exceptional circumstances. Exceptions to notice within five (5) calendar days: a) Fire, b) Floods, c) Embargoes, d) War, acts of war, insurrections, riots, e) Strikes, lockouts or other labor disturbances, f) Or acts of God. 2. A provider so affected shall use reasonable commercial efforts to avoid or remove such causes of nonperformance, and shall provide proper notice hereunder immediately whenever such causes are removed. Changes to the scope of available services or reimbursement methodology for the provision of certain services through legislative or regulatory action shall not constitute an unforeseeable circumstance within the meaning of this section. F. A beneficiary or legal guardian/representative may change, once per election period, the designation of the particular hospice from which hospice care will be received. The change of the designated hospice is not considered a revocation of the election or discharge from hospice services, but is a transfer. 1. The beneficiary or legal guardian/representative must file, with the hospice from which hospice care has been received and with the newly designated hospice, a signed statement that includes the following information: a) The name of the hospice from which the beneficiary currently receives hospice care, b) The name of the hospice the beneficiary chooses to transfer to, and c) The effective date of the transfer. 2. The new hospice provider chosen by the beneficiary or legal guardian/representative must file the transfer notice and complete all assessments as required by the hospice Conditions of Participation and any federal and state laws. G. A beneficiary or legal guardian/representative may revoke the election of hospice care services at any time which results in forfeiture of any remaining days in that election period. 1. The revocation must be in writing and filed with the hospice provider and must include: a) A signed statement that the beneficiary revokes the election for hospice care services for the remainder of that election period, and b) The effective date of the revocation which cannot be earlier than the date that the revocation is made. 2. Verbal revocation of hospice care services is not acceptable. 3. Upon revoking hospice care services, the beneficiary's waived Medicaid benefits will resume. 4. The provider must file a revocation of hospice services notice to the UM/QIO Division of Medicaid or designee within five (5) calendar days after the effective date of the revocation. 5. The beneficiary or legal guardian/representative may, at any time after a revocation, elect to receive hospice coverage for any other hospice election periods the beneficiary is eligible to receive. H. The hospice provider must notify the Division of Medicaid of any discharge by filing a discharge notice within five (5) calendar days after the effective date of discharge. 1. A hospice provider can only discharge a beneficiary as a result of one (1) of the following: a) The beneficiary or guardian/legal representative transfers to another hospice provider, b) The beneficiary moves out of the geographic area that the hospice defines in its service area, c) The beneficiary's condition improves and he/she is no longer considered terminally ill, d) Discharge for cause which is extraordinary circumstances in which the hospice provider would be unable to continue to provide hospice care services. Before seeking a discharge for cause of a beneficiary, the hospice provider must: 1) Advise the beneficiary that a discharge for cause is being considered, 2) Make a serious effort to resolve the problem(s) presented by the beneficiary's behavior or situation, and 3) Ascertain that the beneficiary's proposed discharge is not due to the beneficiary's use of necessary hospice services, 4) Document the problem(s) and efforts made to resolve the problem(s) in the beneficiary's medical records, and 5) Notify the UM/QIO Division of Medicaid or designee of the circumstances surrounding the impending discharge. e) Beneficiary or guardian/legal representative decides to revoke the hospice benefit, or f) The beneficiary dies, 2. The hospice provider, prior to discharging a beneficiary for any reason other than revocation, transfer, or death, must obtain a written physician's discharge order from the hospice medical director. If a beneficiary has an attending physician involved in his or her care, this physician should be consulted before discharge and the physician's review and decision included in the discharge note. 3. A beneficiary, upon discharge from a hospice provider during a particular election period for reasons other than immediate transfer to another hospice, is no longer covered under Medicaid for hospice care and: a) Resumes Medicaid coverage of the benefits waived, if eligible, and b) May at any time elect to receive hospice care if he or she is again eligible to receive the benefit. 4. The hospice provider must have in place a discharge planning process that takes into account the prospect that a beneficiary's condition might stabilize or otherwise change such that the beneficiary cannot continue to be certified as terminally ill. Prior to discharging a beneficiary who is no longer certified as terminally ill, the discharge planning process must include planning for any necessary: a) Family counseling, b) Beneficiary education, and/or c) Other services. I. Hospice providers cannot automatically or routinely discharge a beneficiary at its discretion, even if the hospice care is costly or inconvenient.