S.D. Medicaid Billing and Policy Manual, Hospice Services, Eligible Recipients

Providers are responsible for checking a recipient’s Medicaid ID card and verifying eligibility before

providing services. Eligibility can be verified using South Dakota Medicaid’s online portal.

The following recipients are eligible for medically necessary services covered in accordance with the

limitations described in this chapter:

Coverage Type Coverage Limitations

Medicaid/CHIP Full Coverage Medically necessary services covered in

accordance with the limitations described in this

chapter.

Qualified Medicare Beneficiary – Coverage

Limited (73)

Coverage restricted to copays, coinsurance, and

deductibles on Medicare A and B covered

services.

Refer to the Recipient Eligibility manual for additional information regarding eligibility including

information regarding limited coverage aid categories.

Level of Care Requirements

A recipient may live in a home in the community or in a long-term care facility while receiving hospice

care. A recipient receiving hospice services in a skilled nursing facility, intermediate care facility for

individuals with intellectual disabilities (ICF-IID), swing bed, assisted living center, community support

provider, or inpatient hospice must meet the level of care requirements in ARSD Ch. 67:45:01.

Physician Certification

A written certification statement of terminal illness signed by the medical doctor of the hospice or a

physician member of the hospice interdisciplinary group and the recipient’s attending physician or

licensed nurse practitioner should be obtained within two calendar days after hospice care is initiated.

An individual is considered to be terminally ill if the medical prognosis is that the individual’s life

expectancy is 6 months or less if the illness runs its normal course.

If the hospice does not obtain written certification within two calendar days after hospice care is

initiated, a verbal certification must be obtained within the two calendar days and a written certification

must then be obtained no later than eight days after care is initiated. If the certification requirements are

not met, no payment can be made for hospice care provided prior to the date of any subsequent

certification. The certification statement must include a statement indicating the recipient’s medical

prognosis is a life expectancy of six months or less.

Certification of terminal illness for hospice benefits must be based on the clinical judgment of the

hospice medical director or physician member of the interdisciplinary team and the individual’s

attending physician, if he/she has one, regarding the normal course of the individual’s illness.

In reaching a decision to certify that the patient is terminally ill, the hospice medical director must

consider at least the following information:

• Diagnosis of the terminal condition of the recipient;

• Other health conditions, whether related or unrelated to the terminal condition; and

• Current clinically relevant information supporting all diagnoses.

The written certification must include:

• A statement that the recipient’s medical prognosis is that their life expectancy is 6 months or

less if the terminal illness runs its normal course;

• Specific clinical findings and other documentation supporting a life expectancy of 6 months or

less;

• The physician’s brief narrative explanation of the clinical findings that supports a life expectancy

of 6 months or less as part of the certification and recertification forms, or as an addendum to

the certification and recertification forms; and

The signature(s) of the physician(s), the date signed, and the benefit period dates that the certification

or recertification covers. The signature may be electronic.

Physician Recertification

The hospice must obtain written recertification of terminal illness for each benefit period, even if a single

election continues in effect. The first two benefit periods are for 90 days. After the initial two benefit

periods, all subsequent benefit periods are 60 days. Recertifications may be completed up to 15

calendar days before the start of the next benefit period and no later than 2 calendar days after the

beginning of the period. For the re-certification (for subsequent hospice benefit periods), only the

hospice medical director or the physician member of the interdisciplinary group is required to sign and

date the certification. The recipient’s attending physician is not required to sign and date the

recertification. The certification must include the statement that the recipient’s life expectancy is 6

months or less if the terminal illness runs its normal course. The hospice must retain the certification

statements.

A hospice physician or licensed nurse practitioner employed by the hospice or working under a contract

with the hospice must have a face-to-face encounter with a hospice recipient prior to, but not limited to

more than 30 days prior to the third benefit period recertification and each recertification thereafter to

determine continued eligibility. The face-to-face encounter may occur via telemedicine. The hospice

physician or licensed nurse practitioner who performs the face-to-face encounter with the recipient

must attest in writing that they had a face-to-face encounter including the date and the clinical findings

of the face-to-face visit that support the continued need for hospice services.

Election of Hospice Care Statement

A recipient who is eligible for hospice care or legal representative and who wishes to elect hospice care

must sign an election statement. A recipient or legal representative may designate an effective date for

the election period that begins with the first day of hospice care, but an individual may not designate an

effective date that is earlier than the date that the election is made. The election statement must

include:

• The name of the hospice provider;

• An acknowledgment that the recipient or legal representative understands that hospice provides

palliative, not curative care for the terminal illness;

• An acknowledgment that the recipient or legal representative waives all rights to Medicaid

payments for the duration of the election of hospice care for the following services:

o Hospice care provided by a hospice other than the designated hospice, unless the care

is provided under arrangement made by the designated hospice; and

o Any Medicaid services related to the treatment of the terminal condition for which

hospice care was elected, a related condition, or the equivalent to hospice care, except

services:

▪ Provided directly or under arrangements by the designated hospice;

▪ Provided by the recipient’s attending physician if the physician is not an

employee of or receiving compensation from the designated hospice;

▪ Provided as room and board by a nursing facility or ICF-IID if the recipient is a

resident of the facility;

• The effective date of the election; and

• The signature of the recipient or legal representative.

A legal representative of the recipient may act on behalf of the recipient in all matters pertaining to

hospice care.

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 individual:

• Remains in the care of a hospice;

• Does not revoke the election; and

• Is not discharged from the hospice.

Change of Designation of Hospice Care

A recipient, or legal representative, may change, once in each election period, the designation of the

hospice from which he or she elects to receive hospice care. The change of the designated hospice is

not considered a revocation of the election. To change the designation of hospice programs, the

recipient or legal representative must file, with the hospice from which he or she has received care and

with the newly designated hospice, a signed statement that includes the following information:

• Name of the current hospice;

• Name of the new hospice from which the recipient plans to receive care;

• Date the change is effective.

A change of ownership of a hospice is not considered a change in the recipient’s designation of a

hospice and requires no action on the recipient’s part.

Revocation of Election of Hospice Care

A recipient may revoke the election of hospice care at any time by signing and dating a revocation

statement that indicates the effective date of the revocation of the hospice care. The effective date of

the revocation must be on or after the date the form is signed. After revoking the election, a recipient

may receive any of the Medicaid benefits they waived by choosing hospice care. A recipient may elect

hospice again at any time if they are eligible for hospice care benefits.

If a recipient is eligible for Medicare as well as Medicaid, the hospice benefit must be elected and

revoked simultaneously under both programs.

Hospice Discharge

Once a hospice chooses to admit a Medicaid recipient, it may not automatically or routinely discharge

the beneficiary at its discretion, even if the care will be costly or inconvenient. The election of the

hospice benefit is the recipient’s choice rather than the hospice’s choice, and the hospice cannot

revoke the recipient’s election. Neither should the hospice request or demand that the recipient revoke

his/her election.

Discharge from a hospice can occur as a result of one of the following:

• The recipient decides to revoke the hospice benefit;

• The recipient transfers to another hospice;

• The recipient dies;

• The recipient moves out of the geographic area that the hospice defines in its policies as its

service area.

• The recipient’s condition improves and he/she is no longer considered terminally ill.

The hospice must notify the Division of Economic Assistance of the discharge within 5 working days of

the end of hospice services.

Discharge for cause: There may be extraordinary circumstances in which a hospice would be unable to

continue to provide hospice care to a recipient. These situations would include issues where patient

safety or hospice staff safety is compromised. When a hospice determines, under a policy set by the

hospice for the purpose of addressing discharge for cause, that the recipient’s (or other persons in the

recipient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to

the recipient or the ability of the hospice to operate effectively is seriously impaired, the hospice can

consider discharge for cause. The hospice must do the following before it seeks to discharge a

recipient for cause:

• Advise the recipient that a discharge for cause is being considered;

• Make a serious effort to resolve the problem(s) presented by the recipient’s behavior or

situation;

• Ascertain that the recipient’s proposed discharge is not due to the recipient’s use of necessary

hospice services; and

• Document the problem(s) and efforts made to resolve the problem(s) and enter this

documentation into the recipient’s medical records.

The hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult

Protective Services) as appropriate.

Discharge Order

Prior to discharging a recipient for any reason other than a recipient revocation, transfer, or death, the

hospice must obtain a written physician's discharge order from the hospice medical director. If a

recipient has an attending physician or other licensed practitioner involved in his or her care, this

physician should be consulted before discharge and his or her review and decision included in the

discharge note.

Effect of Discharge

An individual, upon discharge from the hospice during a particular election period for reasons other

than immediate transfer to another hospice:

• Is no longer covered under hospice care;

• Resumes Medicaid coverage of the benefits waived; and

• May at any time elect to receive hospice care if he or she is again eligible to receive the benefit.

Discharge Planning

The hospice must have in place a discharge planning process that takes into account the prospect that

a recipient’s condition might stabilize or otherwise change such that the recipient cannot continue to be

certified as terminally ill. The discharge planning process must include planning for any necessary

family counseling, patient education, or other services before the recipient is discharged because he or

she is no longer terminally ill. Once a recipient is no longer considered terminally ill with a life

expectancy of 6 months or less if the disease runs its normal course, coverage and payment for

hospice care should cease. Medicaid does not expect that a discharge would be the result of a single

moment that does not allow time for some post-discharge planning. Rather, it would be expected that

the hospice’s interdisciplinary group is following the recipient, and if there are indications of

improvement in the recipient’s condition such that hospice may soon no longer be appropriate, then

planning should begin. If the recipient seems to be stabilizing, and the disease progression has halted,

then it could be the time to begin preparing the recipient for alternative care. Discharge planning

should be a process, and planning should begin before the date of discharge.