Ind. IHCP Hospice Services Provider Reference Module, Section 5

Providers are to use current professional guidelines, including the Medicare Local Coverage Determination

(LCD), to determine when hospice services meet medical necessity. The Indiana Health Coverage

Programs (IHCP) recognizes that the LCD is only a guideline to determine when members may be

appropriate for hospice or palliative services. When evaluating the unique clinical condition of each

hospice member, the LCD is not meant to replace the overall clinical evaluation by the hospice provider or

by the IHCP or its contractor.

For dually eligible (Medicare and Medicaid) hospice members, hospice providers should refer to eligibility

requirements in Code of Federal Regulations 42 CFR 418.20, which states: “In order to be eligible to elect

hospice care under Medicare, an individual must be: (a) Entitled to Part A of Medicare; and (b) Certified as

being terminally ill in accordance with 418.22.”

Medicaid-only hospice members must be eligible for the Medicaid program and be certified as terminally

ill in accordance with 42 CFR 418.22. Furthermore, the medical documentation contained in the

Medicaid Hospice Physician Certification form (State Form 48736 [R/12-02]/OMPP 0006) and the

Medicaid Hospice Plan of Care form (State Form 48731 [R2/11-04]/OMPP 0011) must support a terminal

diagnosis versus a chronic condition.

Within the specific context of the hospice benefit, the hospice authorization process consists of the

following two parts:

• Hospice election, plan of care and benefit period process

• Prior authorization (PA) for services not covered by the IHCP hospice per diem as described in

Indiana Administrative Code 405 IAC 5-34-8