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

Hospice revocation is a patient-initiated process. Hospice providers should review Code of Federal

Regulations 42 CFR 418.28 to understand federal regulations about hospice revocation. The IHCP hospice

benefit mirrors federal Medicare regulations and policy for hospice revocation.

Note: State Operations Manual, Section 2082.D specifies that, in states that have a

Medicaid hospice benefit, a dually eligible (Medicare and Medicaid) member

residing in a nursing facility must revoke hospice care under both the Medicare and

Medicaid programs.

If a member, or representative of a member, is not satisfied with hospice care and wishes to revoke hospice

services, the following procedures apply:

• The individual must sign a Medicaid Hospice Revocation form (State Form 48735 [4-98]/

OMPP 0007). This form includes a signed statement that the individual revokes the election of

IHCP hospice services for the remaining days in the election period.

• The member or the member’s representative must revoke hospice care in writing for the hospice

revocation to be valid. Neither the Medicare nor the IHCP hospice benefit recognizes revocation by

action when a hospice patient is noncompliant with the hospice care philosophy.

• The member or the member’s representative must specify the date that hospice revocation is to

be effective. It is the hospice provider’s responsibility to ensure that the member or member’s

representative understands that an individual or individual’s representative cannot designate

an effective date earlier than the date the revocation is made, according to federal regulation

42 CFR 418.28(b)(2).

• If all hospice benefit periods preceding the date of the hospice revocation have been previously

authorized, the hospice provider can submit the Medicaid Hospice Revocation form to the

appropriate IHCP prior authorization and utilization management (PA-UM) contractor (see the

IHCP Quick Reference Guide for contact information).

For fee-for-service (FFS) members, the completed form can be faxed to the FFS PA-UM contractor

or uploaded to the FFS PA-UM provider portal as a revision to the authorization. After the FFS

PA-UM contractor processes the form, the information is transmitted to CoreMMIS. Until the

hospice revocation is reflected in CoreMMIS, no other provider – including nonhospice providers

such as a nursing facility where the member resides – can bill the IHCP for services that are

included in the IHCP hospice per diem.

• For hospice members residing in a nursing facility, hospice providers must provide a copy of the

Medicaid Hospice Revocation form to the appropriate staff in the nursing facility to ensure that the

form is included in the hospice member’s nursing facility clinical record. This requirement ensures

that the nursing facility has this legal document reflecting that the member revoked the Medicaid

hospice benefits and that the facility staff is aware of the exact date the hospice member revoked

hospice care. To ensure better communication about reimbursement issues between the hospice and

nursing facility, the hospice must also develop coordination procedures with the appropriate staff

in the nursing facility billing department so that the nursing facility biller is aware when the member

revoked hospice care. This permits the nursing facility biller to submit claims for nursing facility

care for the service date following the hospice revocation.

• The hospice provider must bill the IHCP for payment of the hospice per diem and for payment of

the nursing facility room and board for the date of the hospice revocation. The reason for this

reimbursement guideline is that the individual is still under hospice care on that day. After the

hospice provider supplies the nursing facility with a copy of the hospice revocation form that has

been processed by the PA-UM contractor, the nursing facility can resume billing the IHCP directly

for nursing facility care for the date of service after the hospice revocation date.

• A member can elect to receive hospice care intermittently, rather than consecutively, over the three

benefit periods. The member can therefore elect and revoke hospice coverage an unlimited number

of times.

• If a member revokes hospice services at any point in the three benefit periods, time remaining in

that benefit period is forfeited.

• If a member reelects the IHCP hospice benefit, the member returns as a reenrollment to the next

eligible hospice benefit period. The hospice provider is required to submit the following forms to

the PA-UM contractor, so that the PA-UM contractor’s hospice analyst can reenroll the member

into the next hospice benefit period:

➢ For Medicaid-only members:

o Medicaid Hospice Election form (State Form 48737 [R2/1-12])

o Medicaid Hospice Physician Certification form (State Form 48736 [R2/12-02]/OMPP 0006)

o An updated Medicaid Hospice Plan of Care form (State Form 48731 [R2/11-04]/OMPP 0011)

➢ For dually eligible members residing in a nursing facility:

o Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility

Residents form (State Form 51098 [3-03]/OMPP 0014)

o The hospice agency’s Medicare hospice election form (with the member’s name, date of

birth and Medicaid Member ID indicated on the form)

For example, if the individual revokes hospice care in the first hospice benefit period and then

reelects, the PA-UM contractor starts the individual in the second hospice benefit period as of the

date the individual signed the election form.

Note: For managed care members, providers should refer to the member’s MCE for specific

procedures and processes around hospice revocation and reelection.