Idaho Medicaid Provider Handbook, Home Health and Hospice Services § 4.3

Hospice services are a benefit of Idaho Medicaid’s enhanced plan. The participant must meet

medical necessity criteria according to the CMS Local Coverage Determination (LCD) L34538,

Hospice Determining Terminal Status to be eligible for hospice services. Only participants with

Medicaid Enhanced Plans are eligible for services. Participants residing in a certified family

home (CFH), intermediate care facilities for individuals with intellectual disabilities (ICF/IID),

residential assisted living facility (RALF), or skilled nursing facility (SNF) are eligible if they

meet the criteria.

There must be a physician certification that the participant’s life expectancy is six months or

less is no more than two days after the participant elects or re-elects to receive hospice

services. The certifying physician must be the hospice medical director or a physician member

of a hospice interdisciplinary group and the participant’s attending physician, if applicable.

Medicaid must be notified if the attending physician is not a hospice employee. The

department may request another physician’s opinion to confirm the diagnosis. The physician

certification must be from within the last six months for election of hospice services.

The participant or their legal representative must elect to receive hospice services by

completing a formal document that selects the hospice, establishes an effective date and is

signed and dated by the participant or their representative. The acknowledgement must

include an understanding of the palliative nature of hospice, and that rehabilitative services,

such as community-based rehabilitation, will no longer be covered. Participants under 21

retain eligibility for curative services and Medicaid benefits. The participant cannot request an

effective date before the date of their election. Participants who elect less than eight monthly

election periods within a benefit period may request additional election periods when:

•

Available hospice did not exceed 210 days in a benefit period due to loss of financial

eligibility;

•

Agencies were not changed excessively;

•

More than eight election periods were not revoked.

A participant can revoke services at any time. A revocation requires filing of a signed

statement with the hospice by the participant that includes revocation of Medicaid hospice

coverage effective the date signed. The hospice provider may not coerce or prevent a

participant’s termination of election. Medicaid coverage will be reinstated the date hospice

election is revoked.

A participant can change hospice agencies at any time by filing a statement with the current

hospice and new hospice agencies. The statement must be signed and dated and include the

names of both hospices and the date the change is effective. Changes in ownership do not

constitute a change in agencies. Participants can only change hospices six times within a

benefit period.

The hospice provider is required to notify the Medical Care Unit (MCU) of all hospice elections,

recertifications, revocations, discharges, transfers or death for Medicaid participants

regardless of other insurance coverage, including Medicare. The provider is required to notify

the MCU within 15 working days by faxing the completed Hospice Notification Form. If the

form is not received timely, Idaho Medicaid will not pay the claim. Factors outside the control

of the hospice provider may create an occasional need for a retrospective review. These will

be considered on a case-by-case basis (e.g., if the participant’s Medicaid eligibility has been

pending).

The MCU determines if the medical necessity criteria for hospice care are met based upon

submitted documentation. If the participant is approved for the Hospice Medicaid Benefit,

election and recertification dates are entered into the Medicaid system as a Hospice Alert. The

notice of decision will be located in the provider portal and the participant will receive a

decision letter in the mail. Hospice care will be approved retrospectively based upon eligibility

date.

Election and recertification are completed every eight months regardless of other payers’

requirements and timelines. Agencies may automatically renew the election period without a

break in care as long as the participant does not revoke the election. Forms are available

under DHW Forms on Gainwell Technologies’ webpage for election, recertification and changes

of status such as revocations, discharges, transfers and death. Forms must be submitted with

the required documentation:

•

The completed Idaho Medicaid Hospice Notification Form;

•

The hospice agency’s completed Interdisciplinary Plan of Care (POC), signed by the

Hospice Medical Director;

•

A certification which states that the individual’s medical prognosis for life expectancy

is six months or less and is signed by the Hospice Medical Director, or the physician in

the hospice interdisciplinary group and the attending physician, if the participant has

one;

•

Elections require the form signed by the participant or legal representative;

•

Elections require the participant’s most recent history and physical performed by the

attending physician regarding the condition qualifying for hospice. This requirement

may also be met with a comprehensive physical assessment signed by the hospice

Medical Director;

•

Recertifications require documentation of compliance with CMS eligibility standards

for the participant’s specific hospice diagnosis (e.g., Local Coverage Determination

(LCD) or Criteria Worksheet); and

•

Changes of Status require the Termination of Care section be completed.

Participants on the Aged & Disabled (A&D) Waiver or Developmentally Disabilities (DD) Waiver

may have waiver service levels adjusted if the participant elects hospice.

Not all participants are eligible for all services. Services are available based on the

participant’s enrollment eligibility. Incarcerated individuals or otherwise ineligible non-citizens

with Medicaid coverage are not eligible for these services.

Before delivery of services, providers must check eligibility on the date of the service to

validate coverage. Providers must maintain documentation of the eligibility check. Eligibility

can be checked by calling Idaho Medicaid Automated Customer Service (MACS) at 1 (866)

686-4272; or through the Trading Partner Account on Gainwell Technologies Idaho Medicaid

website.

See the General Information and Requirements for Providers, Idaho Medicaid Provider

Handbook, for more detail on eligibility checks.