Ind. Admin. Code tit. 405, r. 5-34-6 – Election of hospice services

Sec. 6. (a) In order to receive hospice services, a member must elect hospice services by filing an election statement with the hospice provider on forms specified by the office.

(b) For members at least twenty-one (21) years of age, election of the hospice benefit requires the member to waive Medicaid coverage for the following services:

(1) Other forms of health care for the treatment of the terminal illness for which hospice care was elected, or for treatment of a condition related to the terminal illness.
(2) Services provided by another provider that are equivalent to the care provided by the elected hospice provider.
(3) Hospice services other than those provided by the elected hospice provider or its contractors.

(c) For members less than twenty-one (21) years of age who elect the hospice benefit, the member may receive concurrent curative care services in conjunction with hospice services for the terminal illness. This allows the member or the member's representative to elect the hospice benefit, without forgoing any curative service the member is entitled to under Medicaid for treatment of the terminal illness.

(d) The member or member's representative may designate an effective date for the election that begins with the first day of hospice care or any other subsequent day of hospice care. The individual may not designate an effective date that is earlier than the date of election.

(e) For Medicaid-only hospice member, the Medicaid election form must be submitted to the office along with the Medicaid physician's certification required by section 5 of this rule when hospice services are initiated. It is not necessary to submit the Medicaid election form for the second and subsequent benefit periods unless the member has revoked the election and wishes to reelect hospice care.

(f) For the dually-eligible Medicare/Medicaid hospice member residing in the nursing facility, the hospice agency election form reflecting the Medicare hospice election date and the member's signature must be submitted with the Medicaid hospice authorization form for dually-eligible Medicare/Medicaid nursing facility residents. It is not necessary to submit the Medicare election form for the second and subsequent benefit periods unless the member has revoked the election and wishes to reelect hospice care under the Medicare and Medicaid hospice benefits.

(g) In the event that a member or the member's representative wishes to revoke the election of hospice services, the following apply:

(1) The individual must file a hospice revocation statement on a form approved by the office. The form includes a signed statement that the individual revokes the election of Medicaid hospice services for the remaining days in the benefit period. The form must specify the date that the revocation is to be effective, if later than the date the form is signed by the individual or representative. An individual or representative may not designate an effective date earlier than the date that the revocation is made.
(2) A member may elect to receive hospice care intermittently rather than consecutively over the benefit periods.
(3) If a member revokes hospice services during any benefit period, time remaining on that benefit period is forfeited.
(4) The revocation form must be completed for Medicaid-only hospice members as well as dually-eligible Medicare/Medicaid hospice members residing in nursing facilities. The hospice provider must submit this form to the office.
(5) The Medicaid hospice revocation form must be included in the member's medical chart in the hospice agency. If the Medicaid hospice member resides in a nursing facility, the Medicaid hospice revocation form must be included in the member's nursing facility medical chart as well.

(h) A member or a member's representative may change hospice providers once during any benefit period. This change does not constitute a revocation of services. The following apply when a member changes hospice providers:

(1) To change the designation of hospice programs, the individual or the individual's representative must complete the Medicaid Hospice Provider Change Request Between Indiana Hospice Providers Form or other form designated by the office for this purpose. This form is required for the Medicaid-only hospice member and the dually-eligible Medicare/Medicaid hospice member residing in the nursing facility. The original provider must submit this form to the office.
(2) The Medicaid Hospice Provider Change Request Between Indiana Hospice Providers Form, or other form designated by the office for this purpose, must be included in the member's medical chart in the hospice agency. If the Medicaid hospice member resides in a nursing facility, this form must be included in the member's nursing facility chart. This documentation requirement is for the Medicaid-only hospice member as well as the dually-eligible Medicare/Medicaid hospice member residing in a nursing facility.

(Office of the Secretary of Family and Social Services; 405 IAC 5-34-6; filed Mar 9, 1998, 9:30 a.m.: 21 IR 2381;readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Jun 5, 2003, 8:30 a.m.: 26 IR 3639; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; filed Feb 14, 2013, 9:48 a.m.: 20130313-IR-405120451FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; readopted filed Jul 28, 2022, 2:21 p.m.: 20220824-IR-405220205RFA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)