Vt. Medicaid Hospice Provider Manual § 14

For claim instructions and billing guidelines using the UB-04 claim form visit the VT Medicaid

website. CMS-1500 and UB-04 Billing Guide

Notification of election of hospice:

a. The admitting facility should send DVHA a completed 804B form to indicate when the

Medicaid member elects hospice coverage and to notify DVHA of the admitting facility.

b. When a Medicaid member elects hospice, they could be eligible for Long Term Care (LTC)

Medicaid, community Medicaid, or on a waiver. They must notify their LTC worker/eligibility

specialist of the hospice election.

c. A hospice election form is completed and signed by the member’s physician, the member,

and the agency. If the member has Medicare, the facility or home health agency must

submit the completed hospice election form to Medicare. Once the hospice form is received

by Medicare, the Medicare Eligibility Database is updated to identify the member is on

hospice and the period hospice was approved.

d. Medicare sends hospice information to Vermont Medicaid in daily files. If the information is

not correctly reported to Medicare, and the wrong provider, incorrect level of care, or

incorrect hospice time period is sent to Medicaid, the claims for the member will not pay or

will not pay the correct provider.

e. If a member has both Medicare hospice and Medicaid, Medicare will pay the home health

agency a monthly all-inclusive rate for the hospice services-including medications. If the

member requires care in a nursing home or is on a home and community-based waiver

with supports, Medicaid pays for the hospice room and board in the nursing home or

respite house.

Please reference the VT Medicaid General Billing and Forms manual for timely filing

requirements.