New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 53A - HOSPICE SERVICES MANUAL
Appendix A

Current through Register Vol. 56, No. 18, September 16, 2024

APPENDIX A

I, ________________________________________________________________________ (Beneficiary's Name and Medicaid/NJ FamilyCare fee-for-service Eligibility Identification Number)

elect to receive Medicaid/NJ FamilyCare fee-for-service hospice benefits from:

________________________________________________________________________________

(Name of Hospice Agency and Medicaid Provider Billing Number)

effective this _______ day of _______, 20 _______.

I am aware that I have a life threatening illness. I consent to the management of the symptoms of my disease by the above hospice agency. My family and I will help to develop a plan of care based on our needs. My care will be supervised by my attending physician, ______________________________, and the Hospice Medical Director in conjunction with the hospice interdisciplinary group.

I may receive benefits which include home nursing visits, counseling, medical social work services, medical supplies and equipment. If needed, I may also receive home health aide/homemaker services, physical therapy, occupational therapy, speech-language pathology services, other items and services which are included in the plan of care and otherwise covered by Medicaid, inpatient care for acute symptoms and procedures ordered by my physician, and hospice and continuous nursing care in the home in medical crisis.

I may request volunteer services from the hospice.

In accepting these services, I relinquish my rights to regular Medicaid/NJ FamilyCare fee-for-service benefits, except for services of my attending physician, and for treatment for medical care unrelated to my terminal illness, except when the unrelated services are approved by the hospice interdisciplinary group, or provided in the case of accidental injury, or sudden or serious illness requiring treatment on an emergency basis.

I understand that I can revoke and terminate my hospice benefits at any time and resume regular Medicaid or NJ FamilyCare benefits if I am still eligible for Medicaid or NJ FamilyCare fee-for-service.

I understand that the hospice benefits consist of the following benefit periods: two 90-day periods, and an unlimited number of subsequent 60-day benefit periods. I may be responsible for hospice charges if I become ineligible for Medicaid or NJ FamilyCare.

I am aware that if I choose to revoke hospice benefits during a benefit period, I am not entitled to coverage for hospice services for the remaining days of that benefit period. I understand that should I choose to do so, I am still eligible to receive the remaining benefit period(s).

I understand that, should I choose to do so, I may change the designation of the particular hospice once during the election period by filing a statement with the particular hospice from which care has been received and with the newly designated hospice. I understand that changing hospice providers is not a revocation of the remainder of that election period.

I understand that, unless I revoke the hospice benefits, hospice coverage will continue for 180 consecutive days. After the 180 days of hospice benefits, my benefits will automatically expire unless I choose to request an unlimited number of subsequent benefit periods, upon physician recertification of my continued need for hospice services related to my terminal illness.

I understand that if I am a dually eligible Medicare and Medicaid or Medicare/NJ FamilyCare beneficiary, I must elect to use the Medicare and Medicaid or NJ FamilyCare fee-for-service hospice benefits simultaneously.

Check one:

[ ] I am a Medicare beneficiary and have elected to use the Medicare hospice benefits. My Medicare eligibility for hospice benefits begins on: _______________.

(Date)

[ ] I am not a Medicare beneficiary.

[ ] I am currently a nursing facility resident, residing at:

________________________________________

Facility Name

________________________________________

Facility Address

________________________________________

________________________________________

Signature of the Applicant

FD-378 (03/04) page 2

I, __________________________________, due to the physical/mental incapacity of

(Legal Representative)

_________________________________________________________________________

(Beneficiary's Name and Medicaid/NJ FamilyCare Eligibility Identification Number)

am authorized in accordance with State laws to execute, change or revoke the election of Medicaid hospice benefits on behalf of ____________________________ who has been certified as terminally ill. As the representative for ________________________________, I will sign all necessary forms required for the administration of hospice benefits.

____________________________________________________________

Signature of the Legal Representative

____________________________________________________________

Date

____________________________________________________________

Witness

____________________________________________________________

Date

FD-380 (05/04)

I,__________________________________________________________________,

(Beneficiary's Name/NJ FamilyCare Medicaid Eligibility Identification Number)

revoke the hospice benefits allowed to me by Medicaid/NJ FamilyCare and rendered by:

___________________________________________________________________,

(Hospice Agency Name and Medicaid Provider Billing Number)

effective this ________ day of ____________, 20 _____.

I understand that any remaining days of this election period will not be available to me.

I understand that I may elect hospice services at a later time.

I understand that as of the date of this revocation, if I am still eligible, my regular Medicaid or NJ FamilyCare benefits will be restored.

_____________________________________________

Hospice Beneficiary's Signature or Mark

_____________________________________________

Date

FD-381 (05/04)

Hospice benefits for ___________________________________________________

(Beneficiary's Name and Medicaid/NJ FamilyCare Eligibility Identification Number)

are hereby terminated effective ______________, 20_____, for the following reason.

[ ] Beneficiary is deceased. Date of death is _________________, 20______.

[ ] Beneficiary has not requested extension of Medicaid/NJ FamilyCare Fee-For-Service hospice benefits.

[ ] Beneficiary has become financially ineligible for Medicaid/NJ FamilyCare Fee-For-Service.

[ ] Beneficiary has become medically ineligible for hospice benefits as there is no physician certification or recertification of the terminal illness or need for hospice services.

[ ] OTHER: (Please explain.)__________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

[ ] Condition improved. Inactive status.

_________________________________________________________________

(Hospice Agency and Medicaid Provider Billing Number)

Beneficiary may return to active status at any time a change in condition necessitates.

_______________________________ ____________________

Hospice Medical Director Date

FD-382 (05/04)

I, ________________________________________, as the attending physician of

_________________________________________________________________________

(Beneficiary's Name and Medicaid/NJ FamilyCare Eligibility Identification Number),

who is under my care at this time, hereby certify (or recertify) that this patient is terminally ill, this his/her life expectancy is six months or less provided the illness follows its usual course, and that hospice services are reasonable and necessary for the treatment of this terminal illness or related condition.

_______________________________________________________________

Signature of the Attending Physician

_______________________________________________________________

Print the Attending Physician's Name

_______________________________________________________________

Date

FD-385 (05/04)

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