Sec. 10.09.35.05. Eligibility for and Election of Hospice Care

A. To be eligible for hospice care, written certification of terminal illness shall be obtained by the hospice for each of the election periods listed in Regulation .04 of this chapter. Procedures for certification of terminal illness are as follows:

(1) The hospice shall obtain the written certification before the hospice submits a claim for payment;

(2) If the hospice is unable to obtain written certification within 2 calendar days after an election period begins, an oral certification shall be obtained within 2 calendar days and a written certification shall be obtained before the hospice submits a claim for payment;

(3) Certifications shall be completed not more than 15 calendar days before the start of the election period;

(4) For the initial election period, the hospice shall obtain written certification statements and shall document oral certification statements in accordance with §A(2) of this regulation from:

(a) The medical director of the hospice or the physician member of the hospice interdisciplinary team; and

(b) The attending physician, if there is an attending physician;

(5) For subsequent election periods, certification by one of the physicians listed in §A(4) of this regulation is required;

(6) All certifications shall:

(a) Be signed and dated by the certifying physician; and

(b) Include the date of the election for which the certification applies;

(7) Certifications shall be based on the certifying physician’s clinical judgment regarding the normal course of the recipient’s illness and conform to the following requirements:

(a) Document that the participant’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course;

(b) Clinical information documenting the prognosis of a terminal illness shall accompany the certification and shall be filed in the medical record;

(c) Clinical information for the initial election period may be provided orally and shall be documented in the medical record and included as part of the hospice’s eligibility assessment;

(d) A brief narrative written by the certifying physician:

(i) Shall be included in the certification;

(ii) Shall be located immediately before the certifying physician’s signature or included as an addendum signed by the certifying physician;

(iii) Shall include a statement inserted directly above the certifying physician’s signature and based on a review of the participant’s medical record or examination of the participant;

(iv) Shall reflect the participant’s individual clinical circumstances; and

(v) May not contain checkboxes or standard language used for all participants;

(8) To determine continued eligibility for hospice care, a face-to-face encounter by the hospice physician or the hospice nurse practitioner shall occur:

(a) When a stay across all hospices is anticipated to reach the third election period; and

(b) Not more than 30 days before the third election period and any subsequent election period; and

(9) A narrative associated with an election period requiring a face-to-face encounter shall include:

(a) An explanation of why the clinical findings support a prognosis of a terminal illness; and

(b) A written attestation of the date of the encounter and that the clinical findings were provided to the certifying physician.

B. A recipient 21 years old or older meeting the eligibility requirements and electing to receive hospice care shall file a signed election declaration with the provider which shall contain the following:

(1) A statement that the recipient or the representative elects hospice care for the recipient;

(2) Identification of the provider that will furnish hospice care to the recipient;

(3) The effective date of the election, which may not be earlier than the date that the election is made;

(4) A statement that the recipient or representative acknowledges being given a full description of hospice care and of its palliative rather than curative nature as it relates to the recipient's terminal illness and related conditions;

(5) A statement that the recipient or representative understands that the recipient waives all rights to Program payments for the duration of the election of hospice care for the following services:

(a) Hospice care provided by a hospice other than the provider designated by the recipient or representative, unless provided under arrangements made by the designated provider; and

(b) Any services covered by the Program that are related to treatment of the terminal condition or a related condition, or that are equivalent to hospice care, except for services provided by:

(i) The designated provider;

(ii) Another hospice under arrangements made by the designated provider;

(iii) The recipient's attending physician if that physician is not an employee of the designated provider or receiving compensation from the provider for those services; or

(iv) A nursing facility as room and board, if the recipient is a resident of a nursing facility and would be eligible under the Program for nursing facility services if hospice care was not elected; and

(6) The signature of the recipient or representative.

C. A recipient younger than 21 years old meeting the eligibility requirements and electing to receive hospice care shall file a signed election declaration with the provider which shall contain the following:

(1) A statement that the recipient or the representative elects hospice care for the recipient;

(2) Identification of the provider that will furnish hospice care to the recipient;

(3) The effective date of the election, which may not be earlier than the date that the election is made;

(4) A statement that the recipient or representative acknowledges being given a full description of hospice care and of its palliative nature as it relates to the recipient's terminal illness and related conditions;

(5) A statement that the recipient or representative understands that hospice services shall be made available without forgoing Program payments for curative treatment for the terminal illness; and

(6) The signature of the recipient or representative.

D. The election of hospice care shall be considered to continue uninterrupted through the first election period and through any subsequent election periods and any extended election periods, as long as the participant:

(1) Remains in the care of a provider; and

(2) Does not have the hospice care terminated under the provisions of Regulation .04D of this chapter.

E. The election of hospice care may be revoked by the participant or representative at any time for any reason during an election period or an extended election period. Revocation requires the following:

(1) The participant or representative shall file a statement with the provider that includes the following information:

(a) A statement that the participant or representative revokes the election of Program coverage of hospice care and understands that the participant forfeits the remaining days in the election period;

(b) The date that the revocation is to be effective, which may not be earlier than the date the revocation is made; and

(c) The signature of the participant or representative.

(2) As of the effective date of the revocation of the election of hospice care, the recipient:

(a) Is no longer covered under the Program for hospice care;

(b) Resumes Program coverage of services waived under §B(5) of this regulation; and

(c) Forfeits Program coverage of hospice care for any days remaining in the election period, but may at a future time elect hospice care for any remaining election period for which the recipient is eligible.

F. A participant may designate a new provider of hospice care not more than once during an election period. Designation shall be as follows:

(1) The designation of a new provider is not a revocation of the election of hospice care under §D of this regulation.

(2) To designate a new provider, the participant or representative shall file with the previously designated provider and with the newly designated provider, a statement that includes the following information:

(a) The names of the previously designated provider and the new provider;

(b) The effective date of the change of providers; and

(c) The signature of the participant or representative.

(3) A change in ownership of the provider is not considered a change in the participant's designation of a provider and requires no action on the participant's part.

G. The provider shall maintain the statements described in this regulation and provide copies or related information to the Program on request.