Ga. Medicaid Part II Policies & Procedures for Hospice Services § 705

An individual or representative may revoke the election of hospice care at any time. To revoke the

election of hospice care, the individual must file with the hospice agency a Hospice Revocation

Form. The hospice agency must indicate on the Hospice Revocation Form the reason the individual

has chosen to revoke hospice services, and the fact that he or she is aware of the revocation. The

individual forfeits hospice coverage for any remaining days in that election period. An individual

may not designate an effective date earlier than the date the revocation is made. The hospice agency

must maintain the revocation form in the individual’s medical record at the agency. Note that verbal

revocations of hospice service are not acceptable.

Upon revoking the election Medicaid coverage of hospice care for an election period, an individual

resumes Medicaid coverage of the benefits waived when hospice care was elected, effective the date

of revocation. An individual may at any time elect to receive hospice coverage for any other hospice

election periods for which he or she is eligible. The hospice agency may advise the individual on the

option of revoking the benefit and any advantages or disadvantages of the decision being made.

The Hospice Revocation Form must include at a minimum the items of information below:

705.1. Identification of the hospice agency and/or Medicaid Provider number,

705.2. The effective date of revocation.

705.3. The reason the individual chooses to revoke the benefit.

705.4. The signature of the individual or representative.

705.5. The Social Security number and the date of birth of the individual choosing to revoke

hospice services.

705.6. The Medicare and Medicaid number (if applicable).

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

understanding of the revocation of hospice care; and

705.8. The individual’s or representative’s acknowledgement that he or she resumes Medicaid

coverage for the benefits waived when hospice care was elected effective the date of

revocation.

The Hospice Provider is to provide the DMA-59 with their revocation form when member resides in

a Nursing Facility. If the Hospice provider does not provide the DMA-59 and the member is in a

Nursing Facility, the Nursing Facility should submit it.

On the Hospice Revocation Form the Hospice Provider must specify where the member will be

moved (i.e. home, nursing facility, hospital, etc.). Gainwell Technologies shall return any member

back to the original level of care (i.e. Nursing Facility) (with Medicaid Hospice Revocation Form

(DMA 523) and Medicaid Hospice Election Form (DMA 579)) even though the member’s record

may have a 289 (Institutional Hospice) aid category in the Georgia Medicaid Management

Information System (GAMMIS).

The Nursing Facility is responsible for notifying and working with DFCS to get the category

changed to 210 (Nursing Facility). The Division of Medical Assistance requires that the Medicaid

specific hospice revocation form, found in Appendix C, be used for individuals who are Medicaid

eligible and elect to discontinue hospice services. The hospice agency must complete the HCC

notifying DFCS of the revocation. If an individual chooses to re-elect hospice services, the election

procedures outlined in Section 702 must be followed. The individual enters the beginning of the

benefit period following the period revoked.