Ga. Medicaid Part II Policies & Procedures for Hospice Services § 702

If individual elects to receive hospice care, he or she must sign and file a hospice election form with

the hospice agency designated by the individual to provide the benefit. A hospice election form may

also be filed by a representative acting pursuant to State law. With respect to an individual granted

the power of attorney for the individual or acting as an agent to the individual under a Durable Power

of Attorney for Health Care, State law determines the extent to which the individual may act on the

individual’s behalf.

An election to receive hospice care will be continued from the initial election period and through

subsequent periods as verified by the physician’s certification of continuing hospice eligibility and

without a break in care if the individual remains in the care of the hospice agency and does not

revoke the election or is discharged from hospice services. The hospice election form must be legible

and entirely completed with full name, title, relationship of signatory/ representative, etc. when

instructed and must include at a minimum the items of information indicated and listed below:

702.1. Identification of the hospice that will provide care to the individual.

702.2. The individual’s or representative’s acknowledgement that he or she has been given a

full understanding of hospice care.

702.3. The individual’s or representative’s acknowledgement that he or she understands the

Medicaid coverage of hospice services as relating to other Medicaid services.

702.4. The effective date of the election.

702.5. The signature of the individual or representative.

702.6. The Social Security Number and date of birth of the individual electing the hospice

benefit.

702.7. The Medicaid and Medicare numbers (if applicable).

702.8. The attending physician’s full name and his/her Medicaid provider number/NPI

number.

702.9. Effective 10/1/2015, enter the ICD-10 CM Code, the diagnosis code definition

information and the date of onset. Hospice providers and certifying physicians may not

use Debility and Adult Failure to Thrive (AFTT) codes as the primary diagnosis cited as

cause for the terminal illness.

The Division of Medical Assistance requires that the Medicaid specific hospice election form found

in Appendix C be used for individuals who are Medicaid eligible and elect to receive hospice

services. The hospice agency must ensure that the member’s Election form, a copy of the DFCS

Communicator for the member and the copy of the DMA-59 (for a NF resident), are submitted to

Gainwell Technologies for the initial election lock-in. The MMIS ‘initial’ hospice lock-in or span

remains at a 13 month’ time-period (Example: 9/22/2017 no later than 10/23/2018). However,

providers must continue to have the physician certify member for hospice eligibility per federal

regulations at the 90, 90, 60 days span. In the event of audits, the Hospices must be able to

provide documentation that the certification periods have been followed. To extend the initial

MMIS election span or spans as forfeited, the hospice provider must submit additional information.

See Section 704.

702.10. An individual may designate an effective date for the election period that begins with

the first day of the hospice care (the date the individual signs the hospice election form)

or any subsequent day of hospice care, but an individual may not designate an effective

date that is earlier than the date of the hospice election.

702.11. Upon election of hospice care, the individual will be enrolled in the hospice agency

submitting the election form for care for all benefit periods until the agency indicates

the individual is discharged, transferred or has revoked the hospice benefit (See

Sections 705, 706 and 707). All services related to the terminal illness are required to be

provided by the elected hospice agency. This includes all hospitalizations and physician

services related to the terminal illness except those services performed by the attending

physician. A voluntary election of hospice care on behalf of a child does not waive any

rights to concurrent curative services that are related to the treatment of the child’s

condition for which a diagnosis of terminal illness has been made.