Va. DMAS Hospice Provider Manual ch. IV, Revocation/Termination Of Hospice Services

An individual, or his or her representative, may revoke the election of hospice care at any

time

during

an

election

period

using

the

Hospice

Benefits

Change/Revocation/Termination Statement, (DMAS 421). (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.”) Upon revocation of the hospice

benefit, the individual is no longer covered by Medicaid for hospice care; however, if

eligible, the individual may resume Medicaid coverage under the regular scope of

benefits. The individual may, at any time, elect to receive hospice coverage for any other

benefit period(s) that the individual is still eligible to receive. For individuals enrolled under

Medicaid fee-for-service, the hospice provider must enter the discharge date into the

AE&D portal within five (5) calendar days of the revocation, using the Hospice

Enrollment/Disenrollment Authorization Request form (DMAS 421A). For those enrolled

in a managed care organization, please refer to and follow that particular MCO’s hospice

revocation/termination notification procedures. The DMAS 421 must be maintained in the

individual’s medical record.

CHANGE OF HOSPICE PROVIDER

An individual (or representative) may change the designation of the particular hospice

provider, from which hospice care will be received, once in each election period by signing

the Hospice Benefits Change/Revocation/Termination Statement, (DMAS 421) prior to

provision of hospice services.

The change of the designated hospice provider is not a revocation of the election period

for which it is made. The new provider must maintain the signed DMAS 421 in the

individual’s medical record. The new hospice provider must have a new Request for

Hospice Benefits form (DMAS 420) signed by the individual or representative. The new

provider must enter the admission in the AE&D portal for FFS individuals. For individuals

enrolled in a managed care organization, please refer to and follow that particular MCO’s

hospice procedures for a new provider.