The Indiana Health Coverage Programs (IHCP) requires hospice providers to use designated Medicaid hospice forms for IHCP hospice members. As indicated on this page, certain Medicaid hospice forms are also required for members who are dually eligible for both Medicaid and Medicare and who reside in a nursing facility.
These Medicaid hospice forms contain the necessary information to enroll an individual in the IHCP hospice program and provide the standardization to facilitate workflow for the IHCP prior authorization (PA) contractor.
Completed Medicaid hospice forms for fee-for-service (FFS) members may be uploaded to the Atrezzo Provider Portal or sent to the FFS prior authorization and utilization management (PA-UM) contractor by fax or mail. See the IHCP Quick Reference Guide for contact information.
Hoosier Healthwise members must be disenrolled from managed care and enrolled under FFS coverage prior to receiving hospice benefits. For Hoosier Healthwise members who elect the IHCP hospice benefit, providers must fax the completed Medicaid Hospice Election Form to the IHCP FFS PA-UM contractor, being sure to indicate "Hospice Member Disenrollment From Managed Care" on the fax cover sheet. After submitting the fax, hospice providers should call the IHCP FFS PA-UM Customer Assistance line to confirm the fax was received.
For members enrolled in the Healthy Indiana Plan (HIP), Hoosier Care Connect or Indiana PathWays for Aging programs, refer to the members’ managed care entity (MCE) for hospice form requirements and procedures.
Program of All-Inclusive Care for the Elderly (PACE) participants should contact their PACE program when considering hospice services. Hospice is not required to be provided under PACE, but some PACE programs will provide end-of-life services upon request. If PACE disenrollment is required to access hospice services, the PACE program will facilitate the transition to FFS coverage.
Providers may refer to the Hospice Services provider reference module for more information.
To determine which form you need, please see the following descriptions. To access a form, click the linked form name.
Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents
Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents (State Form 51098/OMPP 0014) – For dually eligible hospice members residing in a nursing facility, the hospice provider must complete this form and ensure that it is signed by the primary hospice nurse so the member can be authorized for the IHCP hospice benefit. The form must be submitted along with a copy of the hospice agency’s election form reflecting the member’s Medicare hospice election and signed by the member or the member’s representative. The IHCP requests that providers include the member’s name, date of birth and Medicaid Member ID on the copy of the Medicare hospice election form submitted to the IHCP.
Note: This form is required only for dually eligible hospice members residing in a nursing facility. It is not required for Medicaid-only hospice members.
Medicaid Hospice Election
Medicaid Hospice Election (State Form 48737/OMPP 0005) – The member or the member's representative must sign this form to elect the hospice benefit and to acknowledge the benefits provided under the hospice benefit. A date in the future for the start of the hospice care may be designated by the member or the member's representative; however, hospice election cannot be designated a day prior to the date the hospice election is signed. In other words, federal regulations and medical record standards prohibit backdating hospice revocations.
Elección Del Hospital (Medicaid Hospice Election - Spanish Version) (State Form 55896) – This form is the Spanish-language version of the Medicaid Hospice Election form.
Note: This form is not required for dually eligible members.
Medicaid Hospice Physician Certification
Medicaid Hospice Physician Certification (State Form 48736/OMPP 0006) – The attending physician and the hospice medical director must certify the first hospice benefit period, the medical reason the individual is eligible for hospice, and that the prognosis for life expectancy is six months or less if the illness were to run its course. The hospice medical director alone can complete and sign the physician certification form for all subsequent hospice benefit periods.
Note: This form is not required for dually eligible members.
Medicaid Hospice Plan of Care
Medicaid Hospice Plan of Care (State Form 48731/OMPP 0011) – This form is for reporting a hospice member's terminal illness and related conditions. The hospice interdisciplinary team completes this form to specify the plan of care. The hospice must include all services and supplies within the hospice per diem that are necessary to treat the member's terminal illness and related conditions. The Medicaid hospice plan of care requires the signature of the hospice medical director and two additional signatures of the hospice interdisciplinary team members listed on the form. If the required three signatures are not present, the provider will be notified that they need to resubmit the form with all required signatures, and the start date of hospice authorization will be modified to reflect the late signature dates. This practice is consistent with the timeliness requirement that all forms have the required signatures within 10 business days from the start of a hospice benefit period.
Note: This form is not required for dually eligible members.
Medicaid Hospice Plan of Care for Curative Care – Members 20 Years and Younger
Medicaid Hospice Plan of Care for Curative Care - Members 20 Years and Younger (State Form 54896) – This form is for reporting on the terminal illness and related conditions of members 20 years of age and younger, when concurrent hospice services and curative treatment are elected. The hospice interdisciplinary team and the curative care team complete this form together, describing both the hospice and curative services to be rendered. The IHCP expects providers from both teams to interact and coordinate all services. The hospice plan of care is supervised by the hospice provider and the curative plan of care by other IHCP providers. The hospice provider must include all hospice services and supplies within the hospice per diem that are necessary to treat the member's terminal illness and related conditions. This form requires the signature of the hospice medical director and two additional signatures from members of the curative care disciplines listed on the form. If the required three signatures are not present, the provider will be notified that they need to resubmit the form with all required signatures, and the start date of hospice authorization will be modified consistent with the late signature dates. This practice is consistent with the timeliness requirement that all forms have the required signatures within 10 business days from the start of a hospice benefit period.
Note: This form is not required for dually eligible members.
Hospice Provider Change Request Between Indiana Hospice Providers
Hospice Provider Change Request Between Indiana Hospice Providers (State Form 48733/OMPP 0009) – This form is used when a hospice member elects to change their hospice provider (allowed once during a hospice benefit period). This form must first be submitted by the current/original provider, along with the Medicaid Hospice Discharge Form, before the change. Upon receipt of the discharge and change forms from the current provider, the hospice reviewer updates the system to reflect the date of hospice discharge. At this time, the new provider can submit this form to indicate they are the new hospice provider. Processing the paperwork from the original/current provider first ensures that the paperwork of the new hospice provider can be authorized with minimal interruption.
Note: When applicable, this form is required both for dually eligible hospice members residing in a nursing facility and for Medicaid-only hospice members.
Change in Status of Medicaid Hospice Patient
Change in Status of Medicaid Hospice Patient (State Form 48732/OMPP 0010) – The hospice must complete and submit this form whenever the hospice member has moved from a private home to an institutional setting, from an institutional setting to a private home or from a prior institutional setting to a new institutional setting. For the IHCP to reimburse nursing facility care for a hospice member, the nursing facility, hospice provider, Area Agency on Aging (AAA) or hospital must complete the Preadmission Screening and Resident Review (PASRR) process for the member. Resources pertaining to the PASRR process can be found on the Division of Aging website at in.gov/fssa/da.
This form is also required when a Medicaid-only member already enrolled in the IHCP hospice benefit becomes eligible for Medicare benefits midway through IHCP hospice care. The hospice member must be enrolled in the Medicare hospice benefit at the same time of Medicare eligibility. In this situation, this form must be completed and sent to the IHCP Hospice Authorization Unit, along with the Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents form and a copy of the agency’s Medicare hospice election form.
Note: When applicable, this form is required both for dually eligible hospice members residing in a nursing facility and for Medicaid-only hospice members.
Medicaid Hospice Revocation
Medicaid Hospice Revocation (State Form 48735/OMPP 0007) – Members may opt to revoke their hospice benefit when the member or the member's representative signs this hospice form. Federal regulations require hospice revocation to be in writing. The effective date of the hospice revocation must be equal to or greater (future) than the date the document is signed. In other words, federal regulations and medical record standards prohibit backdating hospice revocations. Hospice revocation is a patient-initiated action.
Note: When applicable, this form is required both for dually eligible hospice members residing in a nursing facility and for Medicaid-only hospice members.
Medicaid Hospice Discharge
Medicaid Hospice Discharge (State Form 48734/OMPP 0008) – The hospice must complete this form when the patient is discharged from the hospice program because:
- The patient died.
- The patient's prognosis is greater than six months.
- The safety of the recipient or hospice staff is compromised.
- The recipient moved out of the hospice provider's service area.
Hospice discharge is a provider-initiated action.
Note: When applicable, this form is required both for dually eligible hospice members residing in a nursing facility and for Medicaid-only hospice members.