Purpose: This section will assist in determining whether an individual is eligible for Hospice Care benefits.
Current Policy Effective Date: January 1, 2008
Date Last Reviewed: November 30, 2007
Previous Policy: January 1, 2007
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POL 1001C: DETERMINING ELIGIBILITY FOR HOSPICE CARE
1. Applicants Must Meet Basic Eligibility Factors
Reference 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. Applicant must also provide a statement to Hospice saying that they are voluntarily electing hospice care.
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.
4. Benefits Begin Month of Hospice Selection
Once applicants meet the 30-day requirement, benefits must be authorized the first of the month of Hospice selection.
5. SSI Eligibles Do Not Need to Submit Application
If SSI is lost, an application will be required to redetermine eligibility.
6. Applicants Must Meet Income Requirements
Require the countable income to be within the maximum income standard per month. Reference Medicaid Table 1A to see income standards. Reference 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. Reference Medicaid Table 7 to see asset standards. Reference Section M801 to determine if resources are countable.
8. Clients May Continue Receiving Hospice If Entering Nursing Home
If Hospice-eligible clients enter a nursing home after hospice eligibility begins, determine with Hospice if they are paying room and board as part of services.
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. Clients May Not Receive Retroactive Medicaid
Do not authorize retroactive Medicaid for clients, unless they are found eligible under another coverage group allowing retroactive medical assistance.
10. Clients Must Be Reviewed
Clients must be periodically reviewed every 12 months to determine continued eligibility. Reference 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.
11. 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 Uinta Hall.
· Client dies.
· Client determined no longer eligible.
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Reference:
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
Clarifying Information:
1. Applicants Do Not Need to Meet Aged, Blind, & Disabled Factor.
2. Resource Transfer Provisions Do Not Apply.
3. Clients Pay No Patient Contribution.
Training Link: Not available at this time.
Worker Responsibilities:
Determining Countable Income
1. Refer to Section M901 for information on countable income.
Determining Countable Assets
1. Refer to Section M800 for information on determining countable assets.
Approving Benefits
1. Enter program type “ME SS” on SEPA screen in EPICS.
2. Enter subtype “HO” on MERE screen in EPICS.
3. Authorize case on SSRM screen in EPICS, using appropriate code from Medicaid Table 3.
4. Send approval notice from Medicaid Table 16.
Denying Benefits
1. Enter program type “ME SS” in SEPA screen in EPICS.
2. Enter subtype “HO” on MERE screen in EPICS.
3. Deny case on SSRM screen in EPICS, using appropriate code from Medicaid Table 15.
4. Send denial notice from Medicaid Table 16.
Reviewing Cases
1. Refer to Section M1403 for information on reviewing cases.
Closing Cases
1. Close case on SSRM screen in EPICS for the appropriate benefit month, using appropriate code from Medicaid Table 15.
2. Send 10-Day closure notice from Medicaid Table 16 when adverse action has occurred.