W. Va. BMS Provider Manual § 509.5

The Hospice is responsible for enrolling the member who is certified as eligible for Hospice care and who

gives consent to enter the program. Member enrollment in the Hospice Services program requires all of

the following:

1. The physician must determine that the member has a life expectancy of six months or less if the

illness runs its normal course and certifies that assessment in writing;

2. The Hospice provider must complete a plan of care, inform the enrolling member of what

Hospice services will be provided, document the member’s informed consent, and complete a

West Virginia Medicaid Hospice Election Form (HEF-01). The provider must also inform the

member how to disenroll from Hospice care, change providers, and transfer services to another

Hospice; and

3. The member/legal representative, after explanation of Hospice services by the Hospice

provider, must sign and date consent on the completed HEF-01.

To complete the enrollment of the member in Hospice services, the provider must furnish the member

with the following:

•

A copy of the completed and signed HEF-01;

•

A copy of the Plan of Care upon member’s and/or the member’s legal representative’s request,

with descriptions of the nature and scope of the services to be provided, a schedule for providing

them, and a telephone number for contacting the Hospice;

•

A copy of the conditions of enrollment in the Hospice Services program explained to the

member/legal representative by the provider and signed by the member/legal representative; and

•

A copy of the terms of revocation explained to the member/legal representative by the provider

and signed by the member/legal representative.

The member is responsible for reporting other insurance and obtaining health care that is not related to

the terminal illness or disease.