Subsection 144-101-II-43.03 - MEMBER ELIGIBILITY PROCEDURE43.03-1Certification of Terminal IllnessA. No later than two (2) calendar days after the initiation of hospice care the hospice must obtain verbal certification of terminal illness from the Medical Director or the physician on the hospice's Interdisciplinary Team and the member's Attending Physician, if the member has an Attending Physician. The hospice must obtain written certification prepared by both the Medical Director or the physician on the hospice's Interdisciplinary Team and the member's Attending Physician (if he/she has one) and submit a copy of the certification to: Office of MaineCare Services, Classification Review, 11 State House Station, Augusta, ME 04333-0011, before submitting any claim for payment.B. With respect to any subsequent election of hospice benefits, the hospice must obtain written certification of the member's terminal illness from the Medical Director or the physician on the hospice's Interdisciplinary Team before submitting the claim for payment.C. The certification must include: 1. The statement that the member's life expectancy is six (6) months or less if the terminal illness runs its normal course; and2. The signature(s) of the physician(s). The hospice must keep the certification statement(s) in the member's record.
43.03-2Election/Revocation of Hospice BenefitsA member or his/her Representative must choose hospice care by filing an election statement. An election will remain effective as long as the member remains in the care of the hospice and does not revoke the election, regardless of the number of benefit periods elapsed. A new election statement must be filed if the member seeks to obtain hospice care after such benefits have been revoked. A member may designate the effective date for hospice benefits as the first or any subsequent day of hospice care, but the effective date may not be earlier than the date of election.
A.Contents of Election StatementThe election statement must include:
1. Identification of the hospice that will provide care to the member;2. The member's or Representative's acknowledgment that he or she fully understands the palliative rather than curative nature of the hospice care related to the terminal illness;3. The member's or Representative's acknowledgment that he or she understands that the MaineCare services listed in Section 43.03-2(B) and Section 43.05-4 are waived (or subject to limitations) by the election and that the member may be held financially liable for obtaining said services;4. The effective date of the election; and5. The signature of the member or Representative. The hospice must keep the election statement(s) in the member's record.
The hospice must ensure that the member and/or Representative is adequately educated with regard to services waived by the hospice election and financial responsibility of the member for obtaining services that may duplicate services covered under this Section. This education should inform members under the age of 21 or their representatives that medically necessary services are not waived when electing hospice services provided that these services are not duplicative of hospice services.
B.Waiver of Other MaineCare BenefitsFor the duration of the election of hospice care a member waives all rights to MaineCare benefits for the following services only:
1. Hospice care provided by a hospice other than the one designated by the member (unless provided under arrangements made by the designated hospice, or when transferring to another hospice program, see Section 43.03-3);2. Any MaineCare services related to the treatment of the terminal condition for which hospice care was elected, or services that are determined to be related to the treatment of the member's condition (with respect to which a diagnosis of terminal illness has been made); and3. Any MaineCare services equivalent to hospice care, except for services: a. provided either directly or arranged by the designated hospice;b. provided by the member's Attending Physician if he or she is not employed by the designated hospice or does not receive payment from the hospice for those services; orc. provided as room and board by a nursing facility if the member is a resident. See Section 43.05 for additional provisions related to covered and non-covered services.
C.Revoking the Election of Hospice CareA member or representative may revoke the election of hospice care at any time by filing a revocation statement with the hospice which includes a signed statement that:
a) the member revokes the election for MaineCare coverage of hospice care for the remainder of that benefit period and b) the effective date of the revocation. The effective date may not be earlier than the revocation. Any days that are remaining in that benefit period are forfeited as of the effective date of the revocation. The member may re-elect hospice care at any time. He/she does not have to wait until the previous benefit period would have been completed if the revocation had not occurred. Upon revoking hospice care, the member resumes coverage of MaineCare benefits waived upon election of hospice care. A person may elect/revoke hospice care as many times as he or she chooses as long as he or she continues to meet the eligibility standards in Section 43.02. The hospice must forward a copy of the completed revocation statement and the Notice of Consumer Transfer/Death BMS/CS 34 to: Classification Review Unit, Office of MaineCare Services, 11 State House Station, Augusta, ME 04333-0011. The hospice must keep the revocation statement(s) in the member' s record. Even if a member has revoked hospice care one or more times, the member is only eligible for a lifetime total of two ninety (90)-day benefits periods (followed by an unlimited number of subsequent sixty (60)-day periods).
43.03-3Changing From One Hospice to AnotherA. A member may change hospice providers once in each benefit period. The change of hospice is not considered a revocation of the election of hospice services.B. To change hospice providers, a member shall file a signed statement with the hospice where the member was initially enrolled and with the new hospice. If appropriate, the hospice shall assist the member with preparation of the statement. The statement shall include: 1. The hospice from which the member received hospice services;2. The hospice from which the member will receive services; and3. The date the change is effective.C. In order to change providers, notification must be sent to the Department on the Notice of Consumer Transfer/Death BMS/CS 34 by the hospice to which the member is transferring. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-43, subsec. 144-101-II-43.03