N.H. Medicaid Hospice Provider Manual, Vol. II, § 2, Revocation of Hospice Care

The member or his or her agent or legal guardian may revoke the member’s election of hospice care

at any time by completing and signing the hospice care provider’s hospice care revocation form.

If the revocation form cannot be signed at the time of revocation, the following shall occur:

1. The member or his or her agent or legal guardian shall verbally revoke the member’s election

of hospice care, the date of which shall be documented in the member’s medical record; and

2. The member or his or her agent or legal guardian shall complete and sign the revocation form

described above.

The member or his or her agent or legal guardian shall not designate a revocation effective date

earlier than the date the revocation is made as described above.

The designated hospice shall submit a completed Form 282A, “Medicaid Hospice Care Notification

Form” (found on the NH MMIS Health Enterprise Portal at www.nhmmis.nh.gov), specifying the

date that the revocation is to be effective, to the Department within 5-calendar days of a member

revoking his or her election of hospice care.

Effective with the revocation date specified, the member shall no longer be covered under the hospice

benefit, and shall resume eligibility for all NH Medicaid benefits previously waived.

A member who revokes his or her election of hospice care shall be eligible to elect hospice care for

any remaining election periods.