La. Medicaid Services Manual ch. 24 (Hospice) § 24.2

An election statement for hospice care must be filed by the beneficiary or by a person authorized

by law to consent to medical treatment for the beneficiary. (See Appendix A for details regarding

the Notice of Election (NOE) form). For dual eligible beneficiaries, hospice care must be elected

for both the Medicaid and Medicare programs simultaneously.

Reporting Election of Hospice Care

When a beneficiary elects Medicaid hospice, the provider must report initial hospice election to

the hospice unit at Gainwell Technologies within 10 calendar days. Documentation to r eport

beneficiary election of hospice must include the following completed forms:

1. Bureau of Health Services Financing (BHSF) Form Hospice - NOE with type bill

81A or 82A; and

2. BHSF Form Hospice-Certification of Terminal Illness (CTI). (See Appendix B).

A prior authorization (PA) packet, which includes the NOE, CTI, and medical documentation is

required upon the initial election of hospice or if the beneficiary is re-electing hospice during any

hospice benefit period.

It is the responsibility of the hospice provider to make sure the NOE, CTI, and any necessary

attachments are properly completed prior to submitting to the hospice unit at Gainwell

Technologies. The diagnosis code on the NOE and the diagnosis description on the CTI must

match. The attending/referring physician’s name on the NOE and CTI must match.

*All fields must be completed and submitted on the NOE and CTI within the 10 calendar

day time frame. The top portion of the NOE form must be completed by the beneficiary or

their legal representative only. The hospice provider cannot enter any information in the top

section of the form.

If these requirements are not met, reimbursement will not be available for the days prior to receipt.

Reimbursement will be effective the date that BHSF receives the proper documentation.

Providers are advised to contact the hospice unit at Gainwell Technologies to confirm receipt of

NOE/CTI and any documentation submitted if a letter is not received within 30 calendar days of

the hospice election date.

Pending Medicaid Eligibles

The electronic prior authorization (e-PA) system will not allow a provider to enter a request until

the Medicaid eligibility information is placed on the Medicaid Eligibility Verification Systems

(MEVS) and Recipient Eligibility Verifications Systems (REVS ) file. The hospice provider will

not be able to request PA until the beneficiary is deemed eligible for Medicaid. At the time a

beneficiary is determined eligible for Medicaid, the request can be submitted for a retrospective

review through the e-PA system. The begin date will be the hospice date of election or begin date

of Medicaid eligibility whichever is the later date.

Attending Physician

The attending physician is the physician most involved with the beneficiary’s care at the time of

referral and prior to the election of hospice services. If the attending physician and the medical

director of the hospice provider are one and the same, then a physician member of the

interdisciplinary team (IDT) must also sign the BHSF Form Hospice - CTI. (See Section 24.5 –

Provider Requirements for IDT requirements).

The attending physician is the physician identified within the Medicaid system as the provider to

which claims have been paid for services prior to the time of the election of hospice.

If a beneficiary (or legal representative) wants to change their designated attending physician

during an elected benefit period the beneficiary (or legal representative) must file a signed

statement, with the hospice provider, that identifies the new attending physician in enough detail

so that it is with enough detail to clearly indicate which physician or nurse practitioner (NP ) was

designated as the new attending physician. The statement needs to include the following:

1. The effective date of the change;

2. The date that the statement is signed; and

3. The beneficiary’s (or legal representative’s) signature, along with an

acknowledgement that this change in the attending physician is the patient’s (or

legal representative’s) choice.

NOTE: There must be two different signatures on the BHSF Form Hospice - CTI for beneficiaries

electing hospice services. (See Section 24.5 – Provider Requirements for detailed information on

the CTI).

Election Statement Requirements

The election statement must include the following:

1. Identification of the hospice provider that will provide care;

2. The beneficiary’s or their legal representative's signature acknowledging that they

have been informed and fully understands the palliative rather than curative nature

of hospice care, as it relates to the beneficiary’s terminal illness and related

conditions. The legal representative must i ndicate the relationship to the

beneficiary, date the form and list a daytime phone number;

3. Acknowledgment that certain Medicaid services are waived by the election; and

4. The effective date of the election. This date must not be earlier than the date of the

election statement and the beneficiary’s or legal representative’s signature. The

beneficiary or legal representative must enter the date of admission on the top

portion of the form. Hospice providers cannot complete this section. Forms

submitted that do not meet this requirement will be considered incomplete.

The hospice election statement must include the patient’s choice of attending physician after th e

election of hospice services. The beneficiary has the option to keep their current physician after

hospice has been elected or designate a physician member of the hospice team to act as their

attending physician once hospice services have been elected. The election form should include an

acknowledgement by the beneficiary (or legal representative) that the designated attending

physician or NP was the beneficiary’s (or legal representative’s) choice.

In cases where a beneficiary signs the NOE form with an “X”; there must be two witnesses

to sign next to their mark. The witnesses must also indicate relationship to the beneficiary

and list daytime phone numbers. Hospice provider representatives cannot sign as witnesses.

Verbal elections are prohibited.

Legal Representatives

When known relatives exist but persons other than relatives sign the BHSF Form Hospice – NOE,

the non- relative must have legal rights (e.g. a medical power of attorney ) to make medical

decisions for beneficiaries who are physically or mentally incapacitated. Proof of these rights must

be submitted at the time the election for hospice is made. Verbal elections are prohibited.

Definition of Relatives

For purposes of this section, a relative is defined as all persons related to the beneficiary by virtue

of:

1. Blood;

2. Marriage;

3. Adoption; or

4. Court appointed legal guardians.

Election Periods

Hospice services are covered on the basis of periods and require PA. A beneficiary may elect to

receive hospice care during one or more of the following election periods:

1. An initial 90-day period;

2. A subsequent 90-day period; and

3. Subsequent periods of 60 days each (requires PA).

The periods of care are available in the order listed and may be used consecutively or at different

times during the beneficiary’s life span. The hospice IDT must help manage the beneficiary’s

hospice election periods by continually assessing the appropriateness for hospice care, especially

before the beneficiary enters a new election period.

Hospice services will end when a beneficiary’s Medicaid eligibility (including Medically Needy

Spend Down, etc. ) ends. A new NOE form and CTI form is required with updated signatures

whenever the beneficiary is recertified for Medicaid. A PA packet is also required for beneficiaries

whose eligibility ended in a subsequent period. If the beneficiary’s Medicaid eligibility ends during

a benefit period (Spend Down, etc.) all required forms and documentation signed and dated within

the day timeframe must be held by the provider in the beneficiary’s records. Once eligibility is

reestablished, a completed packet can then be submitted timely for retrospective authorization.

Providers are encouraged to communicate with family members regarding the beneficiary’s

Medicaid coverage.

NOTE: It is the responsibility of the provider to verify the beneficiary’s Medicaid eligibility. A

copy of the Medicaid eligibility approval letter should be included in request for PA.

Duration of Election

An election to receive hospice care will be considered to continue through the initial election

period and through the subsequent election periods without a break in care as long as the

beneficiary remains in the care of a hospice provider.

A beneficiary who revokes or is discharged alive during an existing election period will lose the

remaining days in the election period. The beneficiary may at any future time elect to receive

hospice coverage for any other hospice periods for which they are eligible.

Change of Designated Hospice Provider

A beneficiary or their legal representative is allowed to change the designation of the particular

hospice provider from which hospice care will be received once in each election period. The

change of the designated hospice provider is not a revocation of the election for the period in which

it is made. To change the designation of hospice providers, the beneficiary or their legal

representative must file with the hospice provider from which care has been received and the newly

designated hospice provider, a signed statement that includes the following:

1. The name of the hospice provider from which the beneficiary has received care and the

name of the hospice provider from which they plan to receive care; and

2. The effective date of the change.

Within five calendar days following receipt of the filed change form, the new hospice provider

must submit a BHSF NOE/Revocation/Discharge/Transfer (81C/82C) to the Prior Authorization

Unit (PAU) at Gainwell Technologies through e-PA. (See Appendix A for instructions).

A BHSF NOE/Revocation/Discharge/Transfer (81C/82C) must be sent to the PAU through e-PA

when a beneficiary is transferring from the original hospice provider within five calendar days.

NOTE: The BHSF Form Hospice - NOE is also used to update changes in the beneficiary’s

condition and status.

Medicaid Covered Services that are Waived

For the duration of an election of hospice care, a beneficiary who is 21 years of age or older waives

all rights to the following Medicaid covered services:

1. Hospice care provided by a hospice agency other than the hospice agency

designated by the beneficiary or a person authorized by law to consent to medical

treatment for the beneficiary; and

2. If the beneficiary is 21 years or older, any Medicaid services that are related to the

treatment of the terminal condition for which hospice care was elected services for

a related condition, or services that are equivalent to hospice care, except for

services provided by:

a. The designated hospice provider;

b. Another hospice provider under arrangements made by the designated

hospice provider; and

c. The beneficiary’s attending physician if that physician is not an employee

of the designated hospice provider or receiving compensation from the

hospice provider for those services.

Waiver Beneficiaries

Once a beneficiary elects hospice and a provider is chosen that hospice provider assumes all

responsibility for the healthcare needs of the beneficiary related to the hospice illness. The hospice

provider must coordinate all services to ensure there is no duplication of services. The Office of

Aging and Adult Services (OAAS), Office for Citizens with Developmental Disabilities (OCDD),

and hospice providers must ensure that all waiver beneficiaries considering hospice are counseled

thoroughly enough to make an informed decision.

Service Coordination

Medicaid expects the hospice provider to interface with other non-hospice providers depending on

the need of the beneficiary to ensure that the beneficiary’s overall care is met and that non-hospice

providers do not compromise or duplicate the hospice plan of care (POC). This expectation applies

to Medicaid hospice beneficiaries and Medicare/Medicaid (dual eligible) hospice beneficiaries.

The hospice provider must ensure a thorough interview process is completed when enrolling a

Medicaid or Medicare/Medica id beneficiary to identify all other Medicaid or other state and/or

federally funded program providers of care.

Adult Day Health Care Waiver

The Adult Day Health Care (ADHC) Waiver is a Medicaid Home and Community-Based Services

(HCBS) Waiver program that expands the array of services available to individuals with functional

impairments, and helps to bridge the gap between independence and institutional care by allowing

them to remain in their own homes and communities.

ADHC Waiver beneficiaries who elect hospice services may choose to elect ADHC Waiver and

hospice services concurrently. The hospice provider and the beneficiary’s support coordination

agency (SCA) must coordinate ADHC Waiver and hospice services when developing the

beneficiary’s POC. All core hospice services must be provided in conjunction with ADHC Waiver

services. When electing both services, the hospice provider must develop the POC with the

beneficiary, the beneficiary’s caregiver and the SCA. The POC must clearly and specifically detail

the ADHC Waiver and hospice services that are to be provided along with the frequency of services

by each provider to ensure that services are non-duplicative, and the beneficiary’s daily needs are

being met. This will involve coordinating services where the beneficiary may receive services each

day of the week.

The licensed hospice provider must provide all hospice services as defined in 42 Code of Federal

Regulations (CFR) Part 418 which includes nurse, physician, hospice aide/homemaker services,

medical social services, pastoral care, drugs and biologicals, therapies, medical appliances and

supplies, and counseling in accordance with hospice licensing regulations.

Once the hospice program req uirements are met, ADHC Waiver services and Long- Term –

Personal Care Services (LT-PCS) (if applicable) can be utilized for those personal care tasks with

which the beneficiary requires assistance. (See the Medicaid Services Manual, Chapter 9, Section

9.1 for a full description of ADHC Waiver covered services at

https://www.lamedicaid.com/provweb1/providermanuals/manuals/ADHC/ADHC.pdf).

Community Choices Waiver

The Community Choices Waiver (CCW) is a Medicaid HCBS Waiver providing an array of

alternative services to individuals to assist them to live in their own home or community instead

of in a nursing facility or institution.

CCW beneficiaries who elect to receive hospice services, may only receive personal assistance

services (PAS) under this waiver program. PAS includes assistance and/or supervision with

activities of daily living (ADL) and instrumental activities of daily living (IADL) that are

necessary for the beneficiary with functional impairments to remain safely in the community.

CCW beneficiaries who elect hospice services may choose to elect CCW and hospice services

concurrently. The hospice provider and the beneficiary’s SCA must coordinate CCW and hospice

services when developing the beneficiary’s POC. All core hospice services must be provided in

conjunction with CCW services. When electing both services, the hospice provider must develop

the POC with the beneficiary, the beneficiary’s care giver and the SCA. The POC must clearly and

specifically detail the CCW and hospice services that are to be provided along with the frequency

of services by each provider to ensure that services are non-duplicative, and the beneficiary’s daily

needs are being met. This will involve coordinating services where the be neficiary may receive

services each day of the week.

The licensed hospice provider must provide all hospice services as defined in 42 CFR Part 418

which includes nurse, physician, hospice aide/homemaker services, medical social services,

pastoral care, drugs and biologicals, therapies, medical appliances and supplies and counseling in

accordance with hospice licensing regulations.

Once the hospice program requirements are met, then CCW PAS can be utilized for those

personal care tasks with which the beneficiary requires assistance. (See the Medicaid Services

Manual, Chapter 7, Section 7.1 for a full description of CCW covered services at

http://www.lamedicaid.com/provweb1/Providermanuals/manuals/CCW2/CCW.pdf).

Program of All-Inclusive Care for the Elderly

Program of All-Inclusive Care for the Elderly (PACE) is an optional HCBS under the Medicaid

State Plan. PACE is a capitated, managed care program for individuals age 55 or older and meet

nursing facility level of care (NFLOC) and program requirements. The PACE IDT performs an

assessment and develops an individualized POC. PACE programs bear financial risk for all

medical support services required, including comprehensive care to beneficiaries who need end-of-life care, for PACE beneficiaries.

Medicaid will not reimburse a hospice provider for services rendered to hospice beneficiaries

participating in the PACE Program. PACE beneficiaries must voluntarily disenroll from the PACE

program if they would like to receive hospice services from a licensed hospice provider. Hospice

providers must contact the PACE provider before rendering hospice services to ensure that the

PACE beneficiary is no longer enrolled in the PACE program.

Long Term-Personal Care Services

LT-PCS are provided under the Medicaid State Plan and are not included as a waiver service. LT-PCS are services that provide assistance with the distinct tasks associated with the performance of

ADL and IADL.

Beneficiaries who elect hospice services may choose to elect LT-PCS and hospice services

concurrently. The hospice provider and the long- term care access services contractor must

coordinate LT-PCS and hospice services when developing the beneficiary’s POC. All core

hospice services must be provided in conjunction with LT-PCS.

When electing both services, the hospice provider must develop the POC with the beneficiary, the

beneficiary’s care giver and the LT-PCS provider. The POC must clearly and specifically detail

the LT-PCS and hospice services that are to be provided along with the frequency of services by

each provider to ensure that services are non-duplicative, and the beneficiary’s daily needs are

being met. This will involve coordinating services where the beneficiary may receive visits each

day of the week.

The hospice provider must provide all hospice services as defined in 42 CFR Part 418 which

includes nurse, physician, hospice aide/homemaker services, medical social services, pastoral care,

drugs and biologicals, therapies, medical appliances and supplies and counseling. Once the hospice

program requirements are met, then LT-PCS can be utilized for those personal care tasks covered

in the LT-PCS program for which the beneficiary requires assistance. (See the Medicaid

Services Manual, Chapter 30 Personal Care Services (PCS), Section 30.2 for a full description of

LT-PCS covered services at

http://www.lamedicaid.com/provweb1/Providermanuals/manuals/PCS/pcs.pdf).

Additional Personal Care Services

Beneficiaries who are 21 years of age and older may be eligible for additional PCS as defined in

the Medicaid State Plan. Services furnished under the PCS benefit may be used to the extent that

the hospice provider would routinely use the services of the hospice beneficiary’s family in

implementing the beneficiary’s POC.

The hospice provider must provide services to the beneficiary that are comparable to the services

they received through Medicaid prior to their election of hospice. These services include, but are

not limited to the following:

1. Pharmaceutical and biological services;

2. Durable medical equipment (DME); and

3. Any other services required by federal law.

NOTE: The above services are for illustrative purposes only. The hospice provider is not exempt

from providing care if an item or category is not listed.

Beneficiaries under Age 21 Receiving Concurrent Care Hospice

Beneficiaries under 21 years of age who elect hospice shall be eligible for the concurrent care

model of hospice. Concurrent care allows the beneficiary to elect to rec eive life-prolonging

therapies. Life-prolonging therapies consist of any aspects of the beneficiary’s medical POC that

are focused on treating, modifying, or curing a medical condition so that the beneficiary may live

as long as possible, even if that medical condition is also the hospice qualifying diagnosis. When

the beneficiary turns 21 years of age, the concurren t care benefit is no longer available.

Beneficiaries and families may change their election between standard and concurrent care

anytime with the hospice during the hospice benefit period.

The hospice provider is responsible for making a daily visit available and optional to all

beneficiaries under 21 years of age and for coordinating care to ensure there is no duplication of

services. If a daily visit is declined by the beneficiary, or their family, then the hospice provider

must maintain documentation of the date and reason for not making a visit. The daily visit is not

required if the person is not in the home due to hospitalization or inpatient respite stays.

All questionable services and/or treatments w ill be sent for medical review. All treatments and

therapies must be included in the POC. Documentation of therapies and treatment as well as

progress notes are required upon each request for a continuation of hospice care and upon the

initial request for hospice care if the beneficiary is already receiving curative treatment(s).

Durable Medical Equipment

The hospice provider is responsible for providing DME or contracts for the provision of DME for

hospice care. DME necessary for life- prolonging therapy shall be reimbursed separately to the

appropriate provider.

Other Services

Beneficiaries who elect hospice services may also receive early and periodic screening, diagnostic,

and treatment (EPSDT), pediatric day health care (PDHC), PCS, and intermittent or extended

home health services concurrently.

Beneficiaries who elect hospice services may also receive from the following wavier services:

OCDD, New Opportunities Waiver (NOW), Residential Options Waiver (ROW), Supports Waiver

(SW), and Children’s Choice Waiver (CC) concurrently as long as the developmental disabilities

diagnosis is not related to the terminal hospice condition and are not duplicative of hospice care.

The hospice provider must coordinate services with the waiver support coordinator and waiver

services provider to ensure there is no duplication of services.

Coordination of Care

The hospice provider for a beneficiary receiving concurrent care is responsible for facilitating

communication and coordinating services with the beneficiary, beneficiary’s caregiver (if

applicable) and beneficiary’s non-hospice providers to ensure that the beneficiary’s overall care is

met and that services are non-duplicative.

A beneficiary with a serious illness may have multiple subspecialists, along with a pediatrician,

and can continue to receive care from the subspecialist/pediatrician as necessitated by the

beneficiary’s goals of care. The subspecialist/pediatrician shall assist with care coordination for

life-prolonging therapies. The hospice providers and subspecialist/pediatrician shall work together

to ensure a collaborative approach when concurrent care model is being utilized.