Eligibility Online Manual
M1001C Hospice Care
Purpose: This section will assist in determining whether an individual is eligible for Hospice Care.
Current Policy Effective Date: June 1, 2022
Date Last Reviewed: April 29, 2022
Previous Policy: February 1, 2021
POL 1001C: DETERMINING ELIGIBILITY FOR HOSPICE CARE
1. Applicants Must Meet Basic Eligibility Factors
Refer to Section M600 for a description of all basic eligibility factors.
2. Applicants Must Elect Hospice Care And Have Physician Verification
Applicants seeking hospice care must have a physician’s statement with a medical prognosis indicating a life expectancy of six months or less and complete an Election Statement with a Hospice provider.
3. Applicants Must Meet 30-Day Requirement
Applicants must meet a 30-day requirement by any of the following:
Completing 30 days of institutionalization immediately prior to the Hospice election.
Completing an election statement 30 days prior to authorization of benefits with a particular Hospice.
Not completing the 30-day requirement because of death.
Verified as SSI eligible.
Receive Home and Community Based Waiver Services immediately prior to Hospice election.
4. Benefits Begin Month Of Hospice Selection
Authorize benefits beginning the first of the month of the Hospice election statement once the applicant meets the 30-day requirement.
5. SSI Eligibles Do Not Need To Submit Application
Require an application when the client loses their SSI to redetermine continued eligibility for the Hospice program.
6. Applicants Must Meet Income Requirements
7. Applicants Must Meet Resource Requirements
8. Clients May Continue Receiving Hospice If Entering Nursing Home
Clients on the Hospice program who enter a nursing home should remain on the Hospice program and will not have a patient contribution. The hospice provider will bill room and board directly to the fiscal agent.
Hospice benefits must continue to be authorized if clients continue to have a physician’s medical prognosis of six months or less to live. If clients do not have this medical prognosis any longer, screen eligibility under another Medicaid coverage group.
9. Nursing Home Clients Who Need Hospice Care
If a nursing home client stays in the nursing home to receive hospice services, the client will remain on the Nursing Home program and continue to pay the patient contribution to the nursing home.
If a nursing home client leaves the nursing home and enters a hospice facility or receives hospice services at home, switch the client to the Hospice program and pro-rate the patient contribution for any partial month in the nursing home. After this pro-rated payment, the hospice client is no longer required to pay a patient contribution while receiving hospice services outside of the nursing home.
10. Clients May Receive Retroactive Medicaid
Applicants may receive Medicaid benefits if they incurred medical bills during any of the three months prior to application.
Reviewer must verify and determine eligibility separately for each retroactive month to determine whether the case would have been eligible if an application had been made.
11. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Refer to Section M1403 for information on reviewing eligibility.
A review is not required for SSI clients.
Clients must be reviewed for other Medicaid program eligibility before closing cases.
12. Clients May Lose Benefits
The case will close on the first day of the next month when any of the following occur:
Client elects to not receive hospice any longer.
Client does not complete review.
Client enters a public institution, excluding the Geriatric Hall at the State Hospital in Evanston.
Client determined no longer eligible.
Defining Group: 20CFR 435 Subpart F
Social Security Act § 1902(a)(10)(A)(ii)(vii)
Income: 42CFR 435 Subpart K
Resources: 42CFR 435 Subpart L
Timely Determination: 42CFR 435.911
Applicants Do Not Need to Meet Aged, Blind, & Disabled Factor.
Resource Transfer Provisions Do Not Apply.
Clients Pay No Patient Contribution.
1. Finalize eligibility and close benefits in the WES when the applicant is no longer eligible.
2. Allow 15-day closure notice when an adverse action has occurred.