Ind. IHCP Hospice Services Provider Reference Module, Section 4, Election by Member

Concurrent with the certification process (as described in the Hospice Authorization Process section),

a member must elect hospice services by completing a hospice election form indicating a particular hospice

provider. The IHCP requires the following documentation for hospice election:

• For Medicaid-only hospice members:

➢ The Medicaid Hospice Election form (State Form 48737 [R2/1-12]) must be completed in its

entirety and signed by the member or member’s representative. This form can be downloaded

from the Forms page at in.gov/medicaid/providers.

• For dually eligible (Medicare and Medicaid) members residing in a nursing facility:

➢ The one-page notification sheet, Hospice Authorization Notice for Dually Eligible

Medicare/Medicaid Nursing Facility Residents (State Form 51098 [3-03]/OMPP 0014), must be

completed by the hospice provider. This form can be downloaded from the Forms page at

in.gov/medicaid/providers.

➢ A copy of the hospice agency’s election form reflecting the member’s Medicare hospice election

and signed by the member or the member’s representative must be attached. The IHCP requests

that providers include the member’s name, date of birth and Medicaid Member ID on the copy

of the Medicare hospice election form submitted to the IHCP.

The member or member’s representative can designate an effective date for the election that begins with

the first day of hospice care or any other subsequent day of hospice care. The individual cannot designate

an effective date that is earlier than the date of election.

According to United States Code 42 USC 1395d(d)(2) and Indiana Administrative Code 405 IAC 5-34-6(b),

election to the Medicaid hospice benefit requires the member to waive the following:

• Other forms of healthcare for treatment of the terminal illness for which hospice care was elected or

for treatment of a condition related to the terminal illness

• Services provided by another provider equivalent to the care provided by the elected hospice

provider

• Hospice services other than those provided by the elected hospice provider or its contractors