Utah Medicaid Provider Manual, Hospice Care Services § 8-9.2

Election statements are designed and supplied to members by hospice agencies

and must include the following elements:

• Identification of the specific hospice that will provide the hospice care,

• The member’s (or legal representative’s) acknowledgment that they have

been given a full understanding of the palliative rather than curative

nature of hospice care as it relates to the member’s terminal illness,

• For adult members, acknowledgment that the member waives certain

Medicaid services,

• 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,

• Information on individual cost-sharing for hospice services,

• Notification of the individual’s (or legal representative’s) right to receive

an election statement addendum, as set forth by 42 CFR 418.24 (c), if there

are conditions, items, services, and drugs the hospice has determined to

be unrelated to the individual’s terminal illness and related conditions

and would not be covered by hospice,

• Acknowledgment that the member (or legal representative) may revoke

the election of the hospice benefit at any time in the future. Adults must

also acknowledge that revocation of hospice benefits will result in

restoration of Medicaid benefits that were waived at the time of hospice

election,

• Information on the beneficiary and Family Centered Care Quality

Improvement Organization (BFCC-QIO), including the right to immediate

advocacy and BFCC-QIO contact information, and

• Signature of the member or legal representative.

Pediatric hospice agencies must have distinct election statements designed

specifically for members under 21 years of age. This election statement must

inform pediatric members and their legal representatives that by electing

hospice care:

• They do not forfeit curative care that would otherwise be available to

them through the Medicaid State Plan.

o Only services that are not part of the hospice rate can be billed

separately. This election statement must also inform them that

upon turning 21 years of age, they will no longer have concurrent

care benefits and will be subject to the rules governing adults who

have elected Medicaid hospice care.

If the member is not physically or mentally capable, or if the member is under 18

years of age, an election statement may also be filed by a representative

authorized by state law to elect or revoke hospice care or terminate medical care

on behalf of a terminally ill individual.

Medicaid payment for hospice care is not available prior to the day that the

election was filed. The effective date of the election may be the first day of

hospice care or a later date but may be no earlier than the date of the election

statement.

An election to receive hospice care remains effective through the initial election

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

long as the patient:

• Remains in the care of a hospice,

• Does not revoke the election, and

• Is not discharged from the hospice.

A member may elect to receive hospice care during one or more of the following

election periods:

• An initial 90-day period,

• A subsequent 90-day period, or

• An unlimited number of subsequent 60-day periods.