Hospice Program

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• Hospice Program
• Forms and Certifications

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• This training program will focus on the
• required forms for the MO HealthNet
• Hospice Program as well the required due
• dates for each form. In addition,
• information on initial certification and
• recertifications will be provided.

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Hospice Forms

• Physician Certification of Terminal Illness
• Hospice Election Statement
• Hospice Nursing Facility Contract Update
• Notification of Termination of Hospice Benefits

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Hospice Forms cont.

• Hospice forms can be obtained on the MO
• HealthNet Division (MHD) Web site,
• http//www.dss.mo.gov/mhd/providers/index.htm
• All forms can be faxed to the Hospice Unit at
• [phone]. Please do not mail forms
• that have been faxed. Make certain all forms
• sent, faxed or mailed, are legible.

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Submission of Forms

• It is the responsibility of the hospice to
• submit all documentation in a timely manner.
• Reimbursement of hospice claims is dependent
• on receipt of correctly completed documentation.
• If accurate documentation is not submitted to
• MHD timely, hospice claims will deny. Late
• submissions can cause denial of services to
• participants, denial and/or incorrect payments
• to providers.

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Physician Certification of Terminal Illness

• The hospice agency must obtain physician
• certification an individual is terminally ill.
  The
• Certification of Terminal Illness must include
• statement the individuals medical prognosis is a
  life expectancy of six (6) months or less,
• contain the physicians signature(s), and
• be dated by the physician(s) within two (2)
• calendar days after hospice care is initiated.

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Physician Certification cont.

• If the hospice does not obtain a
• completed Physician Certification of
• Terminal Illness within two days after the
• initiation of hospice care, a verbal
• certification may be obtained within
• these two days and written certification
• obtained at a later date.

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The Hospice Election Statement

• An election statement must be submitted for
• each MO HealthNet participant electing the
  hospice benefit
• simultaneous election for those with dual
  Medicare/MO HealthNet coverage and,
• individuals receiving hospice services as a
  private pay client who later becomes
• eligible for MO HealthNet.

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Election Statement cont.

• The participants hospice election date for
• which services may be reimbursed by MHD
• is no earlier than the first date of MO
• HealthNet eligibility. The Hospice Election
• Statement is due within five (5) days of
• execution.

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Recertifications

• For each subsequent election period, the
• hospice must obtain no later than two calendar
• days, a signed and dated Physician Certification
• of Terminal Illness. MHD follows Medicare
• election periods of 90-90-60 days followed by
• an unlimited number of 60-day periods. The
• recertifications for these election periods are
• due to MHD within five (5) days of the
• recertification due date.

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Hospice-Nursing Facility Contracts

• The Hospice-Nursing Facility Contracts form
• is used by the hospice to notify MHD of each
• nursing facility the hospice has a contract
• with. This form must be completed by the
• hospice agency and submitted to the MHD
• Hospice Unit before nursing home room and
• board payments can be made to the hospice.

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Hospice-NursingFacility Contracts cont.

• The hospice and the nursing facility must
• retain a copy of the contract a copy of the
• contract is not to be sent to MHD. The
• hospice must also have on file a copy of an
• IM-62 form for each nursing home resident,
• obtained either from the participant, the
• participants family and/or representative or
• the nursing home.

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Notification of Termination of Hospice Benefits

• The participant or participants representative
• may revoke the hospice benefit at any time by
• filing a Notification of Termination of Hospice
• Benefits form. The effective date of the
• revocation is the date of the participants or
• participants representatives signature unless a
• subsequent date is designated. A designated
• effective date earlier than the date the
  revocation
• is signed is unacceptable.

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Notification of Termination of Hospice Benefits
cont.

• The Notification of Termination of Hospice
• Benefits form is due at MHD within five (5)
• days for the following
• Revocation by patient choice
• Change of designated hospice provider
• Decertification of terminal illness by
  physician
• Discharge due to patient relocation or
• Death of patient while on hospice service.

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Reference Materials

• Additional information regarding the MO
• HealthNet Hospice Program can be found in
• the hospice provider manual, section 13 located
• on the MHD Web site
• http//www.dss.mo.gov/mhd/providers/index.htm

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• Thank you for participating in this
• training program. If you have
• questions regarding the information
• contained in this presentation,
• please contact the Provider
• Education Unit at 573-751-6683.