Wis. ForwardHealth Online Handbook, Hospice, Topic #1138

A member is eligible for hospice services if the following conditions are met:

1. A physician certifies that the member has a terminal illness that reduces their life expectancy to six months or less if the

terminal illness runs its normal course. The physician accomplishes this by completing a Physician

Certification/Recertification of Terminal Illness (F-01011 (08/2019)) form and retaining a copy in the member's records.

2. A member 21 years of age or older elects the hospice benefit and waives regular benefits for care and/or treatment of the

terminal illness or related condition. The member indicates this election by completing and signing the Election of Hospice

Benefit for Members 21 and Older (F-01009B (12/2010)) form. If the member is 20 years of age or under, they indicate

election of the hospice benefit by completing and signing the Election of Hospice Benefit for Members 20 and Under (F-

01009A (12/2010)) form.

3. The hospice notifies ForwardHealth of the member's hospice election through the ForwardHealth Portal or the Notification

of Hospice Benefit Election (F-01008 (05/2023)) form.

4. The attending physician and the interdisciplinary team establish a written POC (plan of care) before hospice services are

provided.