Current through Register Vol. 56, No. 18, September 16, 2024
(a) For the purposes of this subchapter only, the term "applicant" refers to an individual applying for hospice eligibility who may or may not be Medicaid/NJ FamilyCare FFS eligible at the time of application.
(b) In order to receive hospice services, an applicant must be eligible for Medicaid/NJ FamilyCare FFS either in the community or in an institution. Additionally, an applicant is eligible for hospice services in the community if he or she would be eligible for Medicaid if he or she were institutionalized. Eligibility rules are found at N.J.A.C. 10:71, 10:72, and 10:78, incorporated herein by reference. Applicants eligible only for the Medically Needy component of the New Jersey Medicaid program are not eligible for hospice services under the Medicaid State Plan benefit.
1. The transfer of resource provisions of N.J.A.C. 10:71-4.7 apply to applicants seeking hospice services while residing in a nursing facility as well as to applicants seeking eligibility for hospice services in the community but whose income disqualifies them from New Jersey Care. . . Special Medicaid Programs.
2. Applicants not already eligible for Medicaid/NJ FamilyCare FFS but who express interest in hospice services should be referred to the county welfare agency for a determination of eligibility. Applicants already residing in a nursing facility should be referred to the county welfare agency in which the facility is located. Applicants in the community or waiting for placement in a nursing home should be referred to the county welfare agency in their county of residence.
3. The providers of hospice services to Medicaid/NJ FamilyCare beneficiaries enrolled in a managed care organization or HMO shall comply with the procedures of that managed care organization or HMO, including, but not limited to, any prior authorization or other utilization control procedure required.
(c) In addition to financial eligibility, the individual applying for Medicaid/NJ FamilyCare FFS hospice eligibility shall meet the following conditions:
1. He or she shall voluntarily elect the hospice services (see 10:53A-3.2);
2. If eligible for Medicare, he or she shall elect his or her Medicare Part A benefits for hospice care. For dually eligible Medicare and Medicaid hospice beneficiaries, the hospice benefits election applies simultaneously under both the Medicare and Medicaid programs. Thus, Medicare is responsible for the payment of claims for services provided, as first payer of the hospice benefit. Medicaid is responsible for payment for services not covered under the Medicare hospice benefit when those services are Medicaid covered services, such as any co-payment, co-insurance deductibles, if applicable, and those Medicaid covered services listed in 10:53A-3.4(g).
3. He or she shall be certified or recertified as terminally ill by the attending physician (see 10:53A-2.3) and be certified by the attending physician that hospice services are reasonable and necessary for the palliation or management of the terminal illness or related conditions by the completion of the Physician Certification/Recertification for Hospice Benefits Form FD-385 (6/92). A copy of this form shall be part of the medical record at the hospice agency;
4. He or she shall have a plan of care for hospice services established prior to and consistent with the provision of hospice services. (For information on the plan of care, see 10:53A-3.6); and
5. He or she shall waive all rights to the following:
i. Those hospice services provided by a hospice other than the one designated by the beneficiary (unless provided under written arrangements made by the designated hospice); and
ii. Any Medicaid/NJ FamilyCare FFS services that are related to the treatment of the terminal condition for which hospice services were elected, or for a related condition, or for services equivalent to hospice care, except for the following services:
(1) Those provided (either directly or under arrangement) by the designated hospice; and
(2) Those provided by the beneficiary's physician or consulting physician in treatment of the terminal condition, if that physician is not an employee of the designated hospice receiving compensation from the hospice for those services.
(d) Applicants in eligibility categories listed in N.J.A.C. 10:71 and 10:72, incorporated herein by reference, may be eligible for hospice if the applicant meets the criteria listed in (b) and (c) above.
