Wash. HCA Hospice Services Billing Guide, Who is eligible?

In order to elect to receive hospice care through HCA’s hospice program, a client

must have the physician’s hospice certification and meet all of the following:

• Be eligible for one of the following Washington Apple Health programs with

hospice as a covered benefit:

o Alternative Benefits Plan (ABP)

o Categorically needy (CN)

o Medically needy (MN)

o Alien emergency medical (AEM) (Cancer treatment and kidney disease

programs only)

• The client’s physician certifies the client has a life expectancy of six months or

less, which is supported by medical records, including documentation that the

client’s condition is declining.

• The client or an authorized health care representative on the client’s behalf

elects to receive hospice care and agrees to the conditions of the election

statement as described in How are hospice election statements used? and

the What is the hospice certification process?

• The hospice agency must:

o Meet the hospice agency requirements listed in What are the notification

requirements for hospice agencies?

o Notify HCA within five business days of the admission of all clients,

including:

▪ Medicaid-only clients.

▪ Medicaid-Medicare dual eligible clients.

▪ Medicaid clients with third-party insurance.

▪ Medicaid-Medicare dual eligible clients with third-party insurance.

▪ Alien Emergency Medical (AEM) clients currently enrolled in another

program.

Note: The hospice agency is responsible for verifying eligibility

directly with the person or the person’s Department of Social

and Health Services (DSHS) Home and Community Services

Office or Community Services Office.

• The hospice agency provides additional information for a diagnosis when HCA

requests and determines, on a case-by-case basis, the information that is

needed for further review.

• AEM clients that are currently enrolled in the cancer treatment or dialysis

programs may receive hospice care. PA is required prior to admission.

Note: See the Program benefit packages and scope of service

categories webpage for a list of benefit packages.

Note: For a description of a client’s MAGI Family-Related MA

program codes see Appendix E of the ProviderOne Billing and

Resource Guide.