Va. DMAS Hospice Provider Manual ch. IV, Election Of Hospice Care

The election of the hospice benefit is an individual, or his or her representative’s choice.

The hospice benefit is not designed to meet the needs of every individual with a terminal

illness. The individual and his or her family representative must be fully informed of the

services available and any limitation(s) on those services prior to electing the benefit.

Some individuals’ needs can be more effectively met by utilizing other state and/or local

programs and services.

In addition to the provision of core services (physician, nursing, medical social services,

and counseling), all other covered services must be available and provided to meet the

needs of the individual. When an individual elects Medicaid hospice care, the individual

waives rights to those services covered by Medicaid which are also covered by Medicare

and relate to the treatment of his or her terminal illness. Hospice providers are

responsible for the provision of all covered services through one of four per diem rates.

Therefore, any covered services provided after the election of the hospice benefit

becomes the financial responsibility of the hospice provider.

Note that, on April 1, 2011, Virginia’s Medicaid State Plan Amendment incorporated the

federal requirement that children under the age of 21 must be permitted to continue to

receive curative medical services, even if they also elect to receive hospice services. This

change was implemented in order to enforce Section 2302 of the Patient Protection and

Affordable Care Act, termed the “Concurrent Care for Children” requirement. Concurrent

curative care means receiving curative care to eradicate disease or normalize the

underlying health condition, while simultaneously receiving hospice care for physical

symptoms and psychosocial needs at end of life. See end of chapter for additional

information.

The hospice benefit consists of two 90-day periods, followed by an unlimited number of

60-day periods (referred to as election periods). An individual must elect to receive

hospice care in order to receive hospice services. A Request for Hospice Benefits form

(DMAS 420) must be completed by the individual, or the individual’s representative, who

is, because of the individual’s mental or physical incapacity, authorized in accordance

with state law to execute or revoke an election for hospice care. (NOTE: For directions

on how to access the most current version of this form, please refer to the last section of

this chapter, titled “How to Access DMAS Hospice Forms.”) When an individual elects

Medicaid hospice care, the individual waives rights to services covered by Medicaid which

are also covered by Medicare. Therefore, after the hospice benefit is elected, Medicaid

payment will continue for services covered under the Virginia State Plan for Medical

Assistance if those services are not covered by Medicare and the individual meets the

program criteria.

This does not mean a hospice provider may provide fewer services than specified in the

Code of Federal Regulations, Title 42, Part 418, because the services could also be

covered under another Medicaid benefit. For example, since payment to the hospice

provider includes home health aide services, the provider cannot refuse to provide these

services because similar services are available under another benefit. DMAS will

reimburse the hospice provider only for services that are medically necessary. Services

which are duplicative are considered unnecessary. An individual receiving hospice

services may be considered appropriate for personal care services if the services cannot

be provided under the law by home health aide or homemaker services.

Admission and Disenrollment Process for Individuals Enrolled in FFS, Effective January

1, 2020:

• When an individual enrolled in Medicaid fee-for-service elects the hospice benefit,

the hospice provider must enter the hospice admission directly into the Automated

Admission and Disenrollment (AE&D) portal;

• Hospice providers must enter all hospice disenrollments for FFS individuals

directly into the AE&D portal;

• The hospice provider will no longer fax the DMAS 421A form to DMAS; and

• The hospice provider will maintain the DMAS 420, 420A, and 421A forms in the

individual’s record. (Note: For directions on how to access the most current version

of these forms, please refer to the last section of this chapter, titled “How to Access

DMAS Hospice Forms.”

Hospice Enrollment Process for Individuals Enrolled in a Cardinal Care Managed Care

Organization:

• For hospice enrollment of an individual enrolled in a Cardinal Care Managed Care

Organization, please refer to and follow the MCO’s enrollment process.

Hospice care may not be provided by a hospice provider other than that designated by

the individual, unless services are provided under arrangements made by the designated

hospice provider. Any Medicaid services related to the treatment of the terminal condition

for which hospice care was elected are waived, except for services provided by the

individual’s attending physician, if that physician is not an employee of the designated

hospice or receiving compensation from the hospice for those services.

An election period to receive hospice care will continue through the initial election period,

as well as through the subsequent election periods, without a break in care, as long as

the individual remains under the care of hospice and does not revoke the election in

writing.

The election statement must include the following:

•

Identification of the particular hospice provider that will provide care to the

individual;

•

The individual’s (or representative's) acknowledgment that the individual has

been given a full understanding of the palliative, rather than curative, nature of

hospice care as it relates to his or her terminal illness;

•

Acknowledgment that certain Medicaid services are waived by the election of

hospice care;

•

The effective date of the election; and

•

The signature and date of the individual or representative.

If the individual is eligible for Medicare as well as Medicaid, the hospice benefit must be

elected and revoked simultaneously under both programs. The hospice provider is

responsible for completion of the DMAS required Request for Hospice Benefits form,

pages 1 and 2 (DMAS 420). (NOTE: For directions on how to access the most current

version of this form, please refer to the last section of this chapter, titled “How to Access

DMAS Hospice Forms.”) If the provider bills Medicare for hospice services, Medicaid will

accept the Medicare election of benefits forms with the Medicaid required physician

signatures and dates.

Authorization to bill for Medicaid hospice services does not guarantee Medicaid payment

for these services. The following conditions must be met for payment to be made:

•

The individual must be eligible for Medicaid during the dates of service

delivery;

•

The individual must not have revoked the hospice election;

•

The hospice provider must be enrolled with Medicaid during the dates of

service delivery; and

•

The hospice provider must pursue all other payment sources (e.g., Medicare

and other insurance) prior to submitting a claim to DMAS.

DMAS reimbursement is subject to all DMAS and MCO quality management/utilization

review activities.