Wis. ForwardHealth Online Handbook, Hospice, Topic #1173

Either the Election of Hospice Benefit for Members 21 and Older (F-01009B (12/2010)) form or the Election of Hospice Benefit

for Members 20 and Under (F-01009A (12/2010)) form must be completed and filed with the hospice for a member who has

been certified as terminally ill and who elects to receive hospice care. The election date designates the first DOS (date of service)

for which hospice care can be reimbursed by Wisconsin Medicaid. Members 21 and older who sign the election statement waive

regular benefits, except for the services provided by an attending physician. An attending physician is defined as a physician who is

a doctor of medicine or osteopathy enrolled under Wis. Admin. Code § DHS 105.05, and identified by the member as having the

most significant role in the determination and delivery of his or her medical care at the time the member elects to receive hospice

care.

The member may discontinue the election of hospice care at any time and thereby have all benefits reinstated. A Hospice Benefit

Revocation (Non-Recertification)/Voluntary Discharge (F-01010 (08/2019)) form must be completed and filed with the hospice

for a member who has chosen to revoke his or her hospice benefit. A member may choose to reinstate hospice care services after

he or she has discontinued these services. In the event of reinstatement, the documentation requirements of hospice apply.

The hospice is required to obtain a signed Election of Hospice Benefit for Members 21 and Older or an Election of Hospice

Benefit for Members 20 and Under form, or its equivalent, prior to providing hospice services to the member.