Free Wisconsin Medicaid Notification of Hospice Benefit Election, F01008 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1008 (10/08)

STATE OF WISCONSIN HFS 107.31(2)(b), Wis. Admin. Code

WISCONSIN MEDICAID

NOTIFICATION OF HOSPICE BENEFIT ELECTION
ForwardHealth requires certain information to enable the program to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services. This form is mandatory; use an exact copy of this form. ForwardHealth will not accept alternate versions (i.e., retyped or otherwise reformatted) of this form. Hospice benefits are covered services for members enrolled in Wisconsin Medicaid or BadgerCare Plus. Instructions: Type or print clearly. This form has two pages; always complete Section I and any other sections of the form that apply to the member. When complete, mail the form to ForwardHealth, Member Services, P.O. Box 6678, Madison WI 53716-0678. SECTION I -- COMPLETE FOR ALL HOSPICE MEMBERS The member named on this form has elected to receive Medicaid hospice benefits. The member signed the Member Election of Hospice Benefit form, F-1009, on the date indicated below and has been certified by a physician as having six months or less life expectancy if the illness follows its usual course. The member's hospice has the Physician Certification/Recertification of Terminal Illness form, F-1011, on file. Name -- Member (First, Middle Initial, Last) Member ID Name -- Hospice Hospice's National Provider Identifier (NPI) Name -- Attending Physician Attending Physician's NPI Is the Attending Physician Employed by the Hospice? Yes No Date Election Form Signed

SECTION II -- COMPLETE FOR MEMBERS RESIDING IN A NURSING HOME AT THE TIME OF HOSPICE ELECTION The hospice and nursing home named below are in agreement that the hospice shall provide hospice services, while the nursing home shall provide room and board services as defined under COBRA, P.L. 99-272. "Room and board" includes the performance of personal care services, including assistance in the activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of the resident's room, and supervision and assistance in the use of durable medical equipment (DME) and prescribed therapies. ForwardHealth will reimburse the hospice for room and board at 95 percent of the nursing home's current skilled nursing facility (SNF) daily rate, for the appropriate number of days, for the hospice member in the nursing home. The hospice will in turn reimburse the nursing home. Name -- Nursing Home Nursing Home's NPI Level of Care Continued

NOTIFICATION OF MEDICAID HOSPICE BENEFIT ELECTION F-1008 (10/08)

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SECTION III -- COMPLETE FOR MEMBERS ENTERING A NURSING HOME AFTER HOSPICE ADMISSION The hospice and nursing home named below are in agreement that the hospice shall provide hospice services, while the nursing home shall provide room and board services as defined under COBRA, P.L. 99-272. "Room and board" includes the performance of personal care services, including assistance in the activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of the resident's room, and supervision and assistance in the use of DME and prescribed therapies. ForwardHealth will reimburse the hospice for room and board at 95 percent of the nursing home's current SNF daily rate, for the appropriate number of days, for the hospice member in the nursing home. The hospice will in turn reimburse the nursing home. Name -- Nursing Home Nursing Home's NPI Date Admitted to Nursing Home

SECTION IV -- COMPLETE FOR REVOCATION OF HOSPICE BENEFITS The member named below has decided to discontinue the hospice benefit on the date indicated. Member ID Name -- Attending Physician Attending Physician's NPI Is the Attending Physician Employed by the Hospice? Yes No Hospice's NPI Date Member Signed Revocation Form

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