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

Require the countable income to be within the maximum income standard per month. Refer to Medicaid Table 1A to see income standards. Refer to Section M901 to determine if income is countable.

7. Applicants Must Meet Resource Requirements

Require the countable resources to be within the maximum resource limit. Refer to Medicaid Table 7 to see asset standards. Refer to Section M801 to determine if resources are countable.

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 dies.

  • Client determined no longer eligible.