Mont. Medicaid Hospice Policy Manual, Policy 404

FILING AN ELECTION

STATEMENT

A patient who meets the eligibility requirements for

the Medicaid Hospice Program must file an election

statement with a Medicaid approved hospice. If the

patient is physically or mentally incapacitated, his or

her representative may file the election statement.

NOTICE OF ELECTION

(NOE)

The hospice of choice must file the Notice of

Election (NOE) with the Department within 5 calendar

days of the start of Medicaid hospice services.

The NOE should be sent by FAX to 406-444-7743,

Attn: Hospice Program Manager, in order to ensure

timely filing.

• NOTE: It is the responsibility of the

hospice provider to determine

the patient’s Medicaid

eligibility before delivering

Medicaid hospice services.

CONSEQUENCES OF

FAILURE TO SUBMIT

A TIMELY NOTICE OF

ELECTION

When a hospice fails to submit the required NOE within 5

calendar days of the start of Medicaid Services, Medicaid will

not reimburse for days of hospice care from the start of the

hospice services until the date the NOE is received by the

Department.

WAIVER OF

CONSEQUENCES

The Department may waive the consequences of failure to

submit a timely-filed NOE. The Department will determine if a

circumstance encountered by the hospice is exceptional and

qualifies for waiver of the consequence. A hospice must fully

document and furnish any requested documentation to the

Department for a determination of exception.

An exceptional circumstance may be due to, but is not

limited to the following:

1. Fires, floods, earthquakes, or similar unusual

events that inflict extensive damage to the

hospice's ability to operate;

2. A Department system issue that is beyond the

control of the hospice;

3. A newly Medicaid-certified hospice that is

notified of that certification after the Medicaid

certification date, or which is awaiting its user ID

from the Department; or

4. Other situations determined by the Department

to be beyond the control of the hospice.

CONTENT OF NOE

STATEMENT

The Content of the NOE must include the following:

1. Identification of the particular hospice and of

the attending physician that will provide care to

the patient. The patient or representative must

acknowledge that the identified attending

physician was his or her choice;

2. The patient's or representative's

acknowledgement that he or she has been

given a full understanding of the palliative rather

than curative nature of hospice care, as it

relates to the patient's terminal illness;

3. Acknowledgement that certain Medicaid

services, as set forth in the “Waiver of Other

Benefits”, section of this policy, are waived by

the election;

4. The effective date of the election, which may

be the first day of hospice care or a later date,

but may be no earlier than the date of the

election statement; and

5. The signature of the patient or representative.

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 patient:

1. Remains in the care of a hospice;

2. Does not revoke the election; and

3. Is not discharged from the hospice under the

provisions of Hospice Policy 406.

WAIVER OF OTHER

BENEFITS

For the duration of an election period of hospice care, a

patient waives all rights to Medicaid payments for the

following:

1. Hospice care provided by a hospice other than

the hospice designated by the patient (unless

provided under arrangements made by the

designated hospice); and

2. Any Medicaid services that are related to the

treatment of the terminal condition for which

hospice was elected or a related condition or

that are equivalent to hospice care except for

services:

a. Provided by the designated

hospice;

b. Provided by another hospice

under arrangements made by the

designated hospice; and

c. Provided by the patient’s

attending physician if that

physician is not an employee of

the designated hospice or

receiving compensation from the

hospice for those services.

RE-ELECTION OF

HOSPICE BENEFITS

If an election has been revoked in accordance with Hospice

Policy 407, the patient (or his or her) representative, if the

patient is mentally or physically incapacitated), may at any

time file an election, in accordance with this section, for any

other election period that is still available to the patient.

CHANGING THE

ATTENDING PHYSICIAN

To change the designated attending physician, the patient

(or representative) must file a signed statement with the

hospice that states that he or she is changing his or her

attending physician.

1. The statement must identify the new attending

physician, and include the date the change is to

be effective and the date signed by the patient

(or representative);

2. The patient (or representative) must

acknowledge that the change in the attending

physician is due to the patient’s choice; and

3. The effective date of the change in attending

physician cannot be the date the statement is

signed.