Ind. IHCP Hospice Services Provider Reference Module, Section 5, Benefit Periods

Hospice eligibility is available to qualifying IHCP-eligible members in three consecutive benefit periods.

Table 3 lists the benefit periods.

Table 3 – Hospice Benefit Periods

Benefit Period Eligibility

Period I 90 days

Period II 90 days (expected maximum length of time for illness to run its course)

Period III Unlimited number of 60-day periods

For Medicaid-only hospice members, the Medicaid Hospice Election form, the Medicaid Hospice

Physician Certification form and the Medicaid Hospice Plan of Care form together constitute the basis for

determination of the hospice authorization for the first benefit period. Assuming that information is

sufficient and accurate, an initial benefit period of 90 days is approved.

If benefit periods beyond the first 90 days are necessary, for example Periods II or III, recertification on the

Medicaid Hospice Physician Certification form and an updated Medicaid Hospice Plan of Care form are

required for hospice authorization of the next benefit period requested. The Medicaid Hospice Election

form does not need to be completed again unless the patient revoked hospice care or the hospice provider

discharged the patient from hospice care and chose to resume hospice care at a later date. This process is

represented in Table 4.

Table 4 – Hospice Authorization Process for Medicaid-Only Members

Time Period Member Eligibility Election Hospice Authorization Process

First 90 Days Medicaid Hospice

Physician

Certification form

(State Form 48736

[R2/12-02]/OMPP

0006): Box 1

Medicaid Hospice

Election form

(State Form 48737

[R2/1-12])

Medicaid Hospice

Plan of Care form

(State Form 48731

[R2/11-04]/OMPP

0011) for Period I

(90 days)

Hospice

authorization

granted for

first 90 days

Second 90 Days Medicaid Hospice

Physician

Certification form

(State Form 48736

[R2/12-02]/OMPP

0006): Box 2

Medicaid Hospice

Plan of Care form

(State Form 48731

[R2/11-04]/OMPP

0011) for Period II

(90 days)

Hospice

authorization

granted for

second 90 days

Subsequent

60-Day Periods

Medicaid Hospice

Physician

Certification form

(State Form 48736

[R2/12-02]/OMPP

0006): Box 3

Medicaid Hospice

Plan of Care form

(State Form 48731

[R2/11-04]/OMPP

0011) for Period III

(60 days)

Hospice

authorization

granted for

next 60 days

Note: While the IHCP requires hospice providers to request prior authorization for

members at the beginning of each hospice benefit period, the IHCP and its

contractors are not prevented from requesting medical documentation about any

hospice member at any point during that member’s enrollment in the IHCP. This

practice is consistent with the IHCP Provider Agreement.

See Section 4: Hospice Election, Revocation and Discharge for more detailed information about how to

complete hospice authorization paperwork for dually eligible (Medicare and Medicaid) hospice members

residing in a nursing facility and for Medicaid-only members in each of the three hospice benefit periods.