Iowa Medicaid Hospice Provider Manual ch. III § C

For services provided through IA Health Link MCO, refer to the MCO-specific

provider manual for any required hospice forms related to service delivery.

For services provided under Medicaid fee-for-service, the following hospice forms

must be completed by the hospice provider, according to the purpose for each,

and the originals retained in the member’s case file:

• Election of Medicaid Hospice Benefit, form 470-2618. See Appendix A for form

instructions.

• Case Activity Report (CAR), form 470-0042. See Appendix B for form

instructions.

• Revocation of Medicaid Hospice Benefit, form 470-2619. See Appendix C for

form instructions.

NOTE: All hospice forms must be completed, dated, and signed on the day that the

action is effective.

For hospice members who are living in a nursing facility (NF), please note the

following:

• Information needed to complete these forms may require communication with

the NF.

• Any required forms, must be submitted to the Department of Human Services

(DHS) Centralized Facility Eligibility Unit (CFEU) within 2 working days after

the form was completed (per preceding bullet). The mailing, fax, and email

information for the CFEU is included in Appendices A, B, and C.

• Hospice provider reimbursement is directly related to the timely and accurate

completion and submission to the CFEU of all hospice forms. This includes the

hospice provider reimbursement (Revenue Code 651) as well as pass through

NF reimbursement that the hospice provider will forward to the NF.

• A CAR form must be submitted with either the Election of Medicaid Hospice

Benefit form, and/or the Election of Medicare Hospice Benefit form, or the

Revocation of Medicaid Hospice Benefit form at the time of CFEU submission.

• If Medicare is the funding source for the member when hospice services begin,

and if the member becomes Medicaid-eligible at a later date, the hospice

provider must submit the Election of Medicare Hospice Benefit and/or the

Election of Medicaid Hospice Benefit to the CFEU along with the CAR form.

• If a Medicaid member revokes or is discharged from the hospice benefit, any

other Medicaid benefits for which the member is eligible will be initiated. The

hospice provider must insure that notification to the CFEU is made for these

changes.

The submission of forms, as described above for a hospice member living in an NF,

applies to a hospice ICF/ID member. However, submit the CAR and the Election of

Medicaid Hospice Benefit to the CFEU within the two working days requirement.

Also, please note that reimbursement for time for a member living in an ICF/ID is

also dependent on the timely submission of required forms to the DHS CFEU.

In lieu of the Election of Medicaid Hospice Benefit form or the Election of Medicare

Hospice Benefit, an alternate form can be used. An alternate election form must

provide the following information:

1. Identification of the hospice that will provide the care.

2. Acknowledgement that the member has been given a full understanding of

hospice care

3. Acknowledgement that the member waives the right to regular Medicaid benefits,

except for payment to the regular physician and treatment for medical conditions

unrelated to the terminal illness.

4. Acknowledgement that members are not responsible for copayment or other

deductibles.

5. The member’s Medicaid number.

6. The effective date of election

7. The member’s signature.