N.J. Admin. Code § 10:53A-3.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:53A-3.2 - Application procedure for medical and financial eligibility for hospice services

(a) The application procedure for completion of the medical criteria for receiving hospice services is as follows:

1. Individuals requesting or initiating hospice eligibility should be referred to a Medicaid approved hospice to complete the hospice medical eligibility requirements for hospice services through the completion of the Physician Certification/Recertification for Hospice Benefits Form, FD-385 and the Election of Hospice Benefits Statement, FD-378. The hospice agency shall be responsible for confirming Medicaid/NJ FamilyCare FFS eligibility and monitoring on-going eligibility including transition into managed care organizations.

2. The hospice shall notify the agency (that is, the county board of social services (CBOSS), the Division of Youth and Family Services (DYFS), or the medical assistance customer center (MACC) (for SSI beneficiaries), as applicable), that is responsible for maintaining the hospice "indicator" (Special Program Number 15) of the completion of the medical eligibility requirements in (a)1 above. The notification must be done through the use of the Hospice Eligibility Form, FD-383.

i. The date of the signing of the Election of Hospice Benefits Statement, FD-378 determines the date of eligibility for hospice services if the applicant is eligible for Medicaid/NJ FamilyCare FFS.

3. For those cases in which the disability determination for Medicaid eligibility is within the jurisdiction of the Disability Review Section, Division of Medical Assistance and Health Services, the determination of disability for the first six months of hospice services will be based solely on the physician's certification of terminal illness. (See also 10:71-3.11 through 3.13).

i. To ensure the continuity of hospice services after six months, the agency responsible for the eligibility determination (that is, the county welfare agency (CWA)), shall inform the Disability Review Section of the beneficiary's eligibility for hospice services based upon the physician's certification of terminal illness and the determination of financial eligibility.

ii. After the initial six-month period, if it appears that such a beneficiary will require and elects to continue to receive hospice services, the Disability Review Section of the Division shall require medical documentation to validate the disability status based on terminal illness as part of the medical recertification. This documentation is in addition to the Physician's Certification/Recertification for Hospice Benefits Form (FD-385) required under 10:53A-2.3.

(1) The required additional documentation consists of the following:

(A) A statement from the attending physician of the diagnosis(es), prognosis and the stage of illness;

(B) Copies of laboratory test results, biopsy and/or pathology reports, Magnetic Resonance Imaging (MRI) and Computerized Axial Tomography (CAT) results; and

(C) Copies of any other objective medical documentation which supports the diagnosis(es).

(2) Individuals who are over 65 years of age, or receiving Medicare, or receiving Social Security Disability Insurance Benefits under Title II or Supplemental Security Income (SSI) under Title XVI or who could have met the eligibility criteria for Aid to Children with Dependent Children (AFDC) that were in place on July 16, 1996, as set forth in N.J.A.C. 10:81 and 10:82, are not required to be evaluated by the Medicaid Disability Review Section.

(3) The Disability Review Section will identify and track individuals who are required to be evaluated for continuing disability and will contact the provider to initiate the enhanced recertification process.

(b) The application procedure for financial eligibility is as follows:

1. After medical eligibility has been determined, all applicants (whether previously eligible for Medicaid/NJ FamilyCare FFS or not) should be referred to the CWA, DCP&P, or the MACC, as applicable, for hospice financial eligibility processing. If the applicant's Medicaid/NJ FamilyCare FFS eligibility status has not been established, is not known, or is uncertain, the hospice agency shall contact the MACC to determine where to refer the potential applicant.

2. For the beneficiary who had been eligible for regular Medicaid/NJ FamilyCare FFS benefits (such as the Medicaid expansion under NJ FamilyCare as set forth in N.J.A.C. 10:69, Medicaid Only or New Jersey Care . . . Special Medicaid Programs), the CBOSS is responsible for assigning the hospice "indicator" and to notify the hospice, in writing, of the date of Medicaid/NJ FamilyCare FFS eligibility for hospice by returning the Hospice Eligibility Form (FD-383).

3. Exceptions: The instructions in (b)1 and 2 above do not apply if the applicant is eligible through DYFS or SSI. For instructions for those eligible through DYFS or SSI, see (b)4 or 5 below, respectively.

4. If the applicant for hospice services is under the supervision of DYFS, DYFS shall be responsible for assigning the hospice "indicator" and to notify the hospice, in writing, of the date of the Medicaid eligibility for hospice by returning the Hospice Eligibility Form (FD-383).

5. If the applicant for Medicaid hospice services is SSI eligible, the MACC is responsible for assigning the hospice "indicator" and to notify the hospice, in writing, of the date of the Medicaid eligibility for hospice by returning the Hospice Eligibility Form (FD-383). (See N.J.A.C. 10:49, Administration, (Appendix Form #14), for the list of medical assistance customer center.)

6. The medical eligibility materials (copies of the Physician Certification/Recertification for Hospice Benefits, FD-385 form and the Election of Hospice Benefits Statement, FD-378,) shall be forwarded by the hospice to the MACC, CBOSS or DYFS, as applicable.

7. All other applicants for room and board services, including those who would lose SSI because of monthly income shall be referred to the CWA. For individuals determined eligible, see (b)2 above for processing responsibilities.

(c) Rules for retroactive Medicaid/NJ FamilyCare FFS eligibility in N.J.A.C. 10:49, Administration, apply to those beneficiaries eligible for Medicaid/NJ FamilyCare FFS prior to their Medicaid/NJ FamilyCare FFS application for hospice. In addition, the following retroactive eligibility rule applies:

1. No retroactive eligibility payment will be authorized for hospice services prior to the date the Election of Hospice Benefit Statement, FD-378 is signed. Retroactive eligibility for hospice services may be established for up to three months prior to Medicaid eligibility provided the Election of Benefit Statement, FD-378 had been signed. Such cases shall be referred to the following addresses for determination of retroactive eligibility:

i. For SSI beneficiaries:

Retroactive Eligibility Unit

Division of Medical Assistance and Health Services

PO Box 712, Mail Code #10

Trenton, New Jersey 08625-0712;

ii. For Medicaid Only and New Jersey Care . . . Special Program beneficiaries, the county welfare agency of the beneficiary's residence; and

iii. For children in foster care; the Division of Child Protection and Permanency (DCP&P) district office.

2. For an applicant who becomes initially eligible for Medicaid, solely because of his or her hospice status, Medicaid eligibility begins with the date the Election of Hospice Benefits Statement, FD-378 was signed by the applicant, or his or her representative. In these cases, retroactive eligibility is not available prior to the date on the Election of Hospice Benefits Statement, FD-378.

(d) The hospice shall notify the agency determining eligibility (MACC, CBOSS or DYFS) through a copy of the Hospice Eligibility Form, FD-383 of a change in the beneficiary's status which could affect the eligibility for Medicaid/NJ FamilyCare and/or for hospice services, a change in the hospice provider status, or a change in a beneficiary's address. The CBOSS, DYFS, or MACC will be responsible for notifying the Social Security Administration of the beneficiary's change in status, if applicable.

(e) A limited access Health Benefits Identification (HBID) Card shall be issued to a fee-for-service Medicaid beneficiary who is eligible for hospice services. The hospice shall provide the name and telephone number of the contact person within the hospice so that other providers may obtain approval from the hospice for other than hospice and physician services.

(f) For Medicaid/NJ FamilyCare beneficiaries who are also enrolled in a commercial managed care organization or HMO, the hospice provider shall coordinate services and obtain approval from the private HMO as the primary payer.

(g) For Medicaid/NJ FamilyCare beneficiaries enrolled in managed care plans, hospice services are provided by their HMO. The HMO procedures of the beneficiary's particular HMO shall apply to hospice services.

N.J. Admin. Code § 10:53A-3.2

Amended by 48 N.J.R. 134(a), effective 1/19/2016