Ind. IHCP Hospice Services Provider Reference Module, Section 5, Election, Plan of Care and Benefit Period Process

When an eligible member elects to receive services from a certified hospice provider, a plan of care must be

developed. Unless the member is dually eligible for Medicare and Medicaid, the Medicaid Hospice Plan of

Care form must be used. This form must be submitted to the appropriate IHCP PA-UM contractor along with

the Medicaid Hospice Election form and the Medicaid Hospice Physician Certification form. See Section 4:

Hospice Election, Revocation and Discharge in this module for more information about the Medicaid Hospice

Election form.

For concurrent hospice and curative care recipients, providers must submit an updated plan of care,

including delineation of hospice and curative care services, to the IHCP PA-UM contractor. The Medicaid

Hospice Plan of Care for Curative Care – Members 20 Years and Younger form (State Form 54896 [2-12])

is available on the Forms page at in.gov/medicaid/providers to allow providers to include information

related to the curative care services.

The following requirements apply to development of the plan of care:

• The interdisciplinary team member who drafts the plan must confer with at least one other member

of the interdisciplinary team.

• One of the conferees must be a licensed physician or nurse, and all team members must review the

plan of care.

• All the services stipulated in the plan of care must be reasonable and necessary for palliation or

management of the terminal illness and related conditions.

• For concurrent hospice and curative care recipients, the Medicaid plan of care must include the

information identified in this section, in addition to the following:

➢ A coordinated plan of care must be prepared and agreed on by the interdisciplinary team and the

providers rendering the curative care.

➢ The plan of care must include the following:

o Assessment of the recipient’s needs

o Identification and delineation of the curative and hospice care services, including the scope and

frequency of the services, and the manner in which the services and assessments are coordinated

o Criteria for terminating the curative care services

• The plan of care and advance directive must be included in the medical charts, including providers

rendering concurrent curative care treatment.

• The plan of care must be signed by the hospice medical director and include two signatures from

any of the other disciplines listed on the Medicaid Hospice Plan of Care form. Failure to include the

three required signatures results in the return of the hospice authorization forms so that the hospice

provider can make the required corrections.

In addition, the hospice provider must comply with Section 1902(a)(57) of the Social Security Act, whereby

the hospice:

• Provides written information to patients about their rights under state law to make decisions

concerning medical care, including the right to accept or refuse medical or surgical treatment and

the right to formulate advance directives

• Provides written information to individuals about the institution’s or program’s written policies

regarding the implementation of the right to formulate an advance directive

• Documents in the patient’s medical record whether an advance directive has been executed

• Complies with all advance directive requirements of state law

• Provides individual or group education on advance directives for staff and the community

• Prevents the placement of conditions on the provision of care as well as discrimination against an

individual who has executed an advance directive