Iowa Medicaid Hospice Provider Manual, APPENDIX A

Click here to view the form online.

A. Purpose of Form

The purpose of the form is to accurately record the date on which a Medicaid

member chooses the Medicaid hospice benefit.

B. When the Election of Medicaid Hospice Benefit Must be Completed

This form must be completed on the date when a Medicaid-eligible member or

legal representative chooses to receive the Medicaid hospice benefit.

Special note for dual eligibility for Medicare and Medicaid: Any member

who is eligible for hospice services under the Medicare benefit, must access

funding through the Medicare benefit. Only members who are determined

ineligible for Medicare can receive hospice services funded by Medicaid. If the

Medicare member becomes eligible for Medicaid funding only; and, chooses to

continue to receive hospice, the member must sign the Election of Medicaid

Hospice Benefit to reflect the date that Medicaid hospice services began after

Medicare hospice ended.

C. Responsibility for Completion

The hospice provider may assist the member or the legal representative with

completion of this form, if needed. The member or the legal representative must

sign and date the form.

D. Instructions

1. Section 1 – Medicaid Information

Recipient Name. Enter the Medicaid member’s name as it appears on the

Medical Assistance Eligibility Card.

Medicaid Number. Enter the member’s state identification number (SID) as

it appears on the Medical Assistance Eligibility Card. This number consists of

seven numeric characters and an ending alphabetic character.

If the member has both Medicare and Medicaid eligibility, add the member’s

Medicare number under the member’s SID.

Beginning Date of Care. Enter the date hospice service was first provided.

If the member received hospice services funded through Medicare before

becoming Medicaid eligible, the Election of Medicaid Hospice Benefit must be

completed with the date that Medicaid hospice services began.

Hospice Name. Enter the hospice provider’s name.

Medicaid Provider Number. Enter the hospice’s seven-digit Iowa Medicaid

identification number.

Attending Physician Name and Phone Number. Enter this information if

the attending physician is not an employee or contracted with the hospice

provider.

2. Section 2 – Medicare Information

Medicare Patient Name. Enter the member’s name as it appears on the

Medicare card.

Medicare Claim Number. Enter the Medicare claim number as it appears

on the Medicare card.

Begin Date. Enter the date Medicare hospice coverage began.

End Date. Enter the date Medicare hospice benefit was terminated, if

applicable.

3. Section 3 – Nursing Facility Information

Facility Name. Enter the name of the NF.

Medicaid Provider Number. Enter the facility’s seven-digit Iowa Medicaid

provider number. ICF level always begins with 080 and SNF level always

begins with 065.

Facility Address. Enter the complete mailing address of the facility.

4. Section 4 – Hospice Change

Present Hospice. Enter the provider name for the hospice before the

change.

Medicaid Provider Number. Enter the provider number for the hospice

before the change.

Effective Date of Change. Enter the last date that the hospice provider

provided services before the change.

New Hospice. Enter the provider name for the hospice after the change.

Medicaid Provider Number. Enter the provider number for the hospice

after the change.

Effective Date of Change. Enter the first date that the hospice provider

provided services after the change.

Special Note: Completing Form for a Change of Hospice Providers.

Section 1. Medicaid Information, and Section 5. Signatures, also need to be

completed for a change in hospice providers. No other sections on the form

need to be completed.

5. Section 5 – Signatures

Recipient’s Signature or Mark. The hospice provider may assist the

member or legal representative with completion of information on the form.

The member or legal representative must sign this section

Date. The member or legal representative must write the date the form was

signed.

Witness’ Signature. The person who witnessed the member’s or legal

representative’s signature must sign this form.

• A legal representative who witnessed the member’s signature can sign

this form.

• A hospice staff who witnessed the member’s or the legal representative’s

signature cannot sign as a witness for this form. Enter the date this form

is signed.

Date. The witness must date this form.

• A legal representative who witnessed the member’s signature can date

this form.

• A hospice staff who witnessed the member’s or the legal representative’s

signature cannot date this form.

6. Section 6 – Distribution

• Retain the original in the member’s case file.

• Send a copy to the member or the legal representative.

• If the member resides in an NF, send a copy to the:

• Nursing facility.

• DHS CFEU within two days of action, by mail, fax or email per the

information below:

Mailing Address:

DHS CFEU

Imaging Center 1

Iowa Department of Human Services

417 E. Kanesville Blvd.

Council Bluffs, IA 51503-4470

Fax: 515-564-4040

Email: facilities@dhs.state.ia.us