N.H. Medicaid Hospice Provider Manual, Vol. II, § 2, Election (or Discharge Due to Death) of Hospice Care

In accordance with He-W 544, if a member seeks to elect hospice care, the hospice provider shall

obtain an election statement via the hospice care provider’s hospice care election form, signed and

dated by the member or his or her agent or legal guardian, indicating the member’s election of

hospice care. The election statement must:

1. Specify the hospice provider designated by the member to provide care;

2. Specify the effective date of the election, which shall not be earlier than the date the member

or his or her agent or legal guardian signs the election statement; and

3. Specify that by waiving rights in accordance with He-W 544, the member or the member’s

agent or legal guardian acknowledges 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 member’s terminal

illness specified on the form. (See “Covered Services” – “Coverage for Children” for further

information on waiving rights.)

If a member elects hospice care, the designated hospice provider shall notify the Department of the

effective date of the election by submitting Form 282A, “Medicaid Hospice Care Notification Form,”

within 5 state business days of the election.

Each hospice provider shall notify the Department of a member’s discharge from the hospice due to

the member’s death, within 5 state business days of the member’s death, via Form 282A, “Medicaid

Hospice care Notification Form.”

These and other forms can be found on the NH MMIS Health Enterprise portal at

www.nhmmis.nh.gov.