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

Current through Register Vol. 56, No. 14, July 15, 2024
APPENDIX A
Form #1
Election of Hospice Benefits Statement (FD-378)
Form #2
Hospice Benefits Statement (FD-379)
Form #3
Representative Statement for the Election of Hospice Benefits
(FD-380)
Form #4
Revocation of Hospice Services (FD-381)
Form #5
Termination of Hospice Benefits (FD-382)
Form #6
Hospice Eligibility form (FD-383), with Instructions for
Submitting the Hospice Eligibility form (FD-383)
Form #7
Change of Hospice form (FD-384)
Form #8
Physician's Certification/Recertification For Hospice Benefits
Form (FD-385)
Form #9
Notification From Long-Term Care Facility of Admission or
Termination of a Medicaid Patient (LTC-2)
Form #10
Statement of Available Income for Medicaid Payment (PR-1)
Form #11
Long-Term Care Turnaround Document (TAD) (MCNH-117)
FORM #1
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
ELECTION OF HOSPICE BENEFITS STATEMENT
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
FORM #2
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
HOSPICE BENEFITS STATEMENT
_______________________________
______________________________
Beneficiary's Signature or Mark
Beneficiary's Name (Print or Type)
_______________________________________________________
Medicaid/NJ FamilyCare Eligibility Identification Number
______________________________
______________________________
Witness' Signature
Relationship to Hospice Beneficiary
______________________________
______________________________
Date Signed
Effective Date of Election
............................................................................
SECOND CERTIFICATION PERIOD (90 days)
(To be signed only if benefits are previously revoked or temporarily
terminated)
______________________________
______________________________
Beneficiary's Signature or Mark
Beneficiary's Name (Print or Type)
______________________________
______________________________
Witness' Signature
Relationship to Hospice Beneficiary
______________________________
______________________________
Date Signed
Effective Date of Second Period
............................................................................
THIRD CERTIFICATION PERIOD (unlimited 60 days) (To be signed only if benefits
are previously revoked or temporarily terminated)
______________________________
______________________________
Beneficiary's Signature or Mark
Beneficiary's Name (Print or Type)
______________________________
______________________________
Witness' Signature
Relationship to Hospice Beneficiary
______________________________
______________________________
Date Signed
Effective Date of Third Period
Add additional periods if necessary.
FD-379 (05/04)
FORM # 3
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
REPRESENTATIVE STATEMENT FOR THE ELECTION OF HOSPICE BENEFITS
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)
FORM # 4
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
REVOCATION OF HOSPICE BENEFITS
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)
FORM # 5
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
TERMINATION OF HOSPICE BENEFITS
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)
FORM # 6
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
HOSPICE ELIGIBILITY FORM
THIS SECTION TO BE COMPLETED BY THE HOSPICE AGENCY
[ ] Initial application
[ ] Change in status
[ ] Change of address
1. Beneficiary's Name ______________________________________________________
2. Medicaid Eligibility Identification Number (MEIN) _______________________
3.
Beneficiary's Address
4.
Birthdate:
___________________________
Sex: Male [ ] Female [ ]
___________________________
SSN:____________________
___________________________
Race:___________________
5.
Is the beneficiary currently receiving Room and Board Service in a
nursing facility:
Yes [ ] No [ ] If yes, give name and address of facility:
6.
Medicare entitlement:
PART A Yes [ ] No [ ]
PART B Yes [ ] No [ ]
HIC # _____________
7.
Medicaid eligibility: Yes [ ] No [ ] Unknown [ ]
If no, give the name of the person, the relationship to beneficiary, and the
telephone number of the person who will initiate the Medicaid application.
_____________________________________________________________
8.
Other insurance (Include company name, policy number, and policy
holder):
___________________________________________________________________________
9.
[ ] Election of hospice benefit on __________________________
Physician Certification on ____________________________
10.
[ ] Termination of benefit on ____________________________
Reason: Death [ ] Revocation [ ] Other (Explain)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
11.
[ ] Change of hospice provider on _____________________________________
From: _____________________ Medicaid Provider Billing No. _____________
To: _____________________ Medicaid Provider Billing No. _______________
Name, Address and Medicaid Provider Billing Number of provider submitting
form:
________________________________________________________________
________________________________________________________________
Contact person and telephone number: ___________________________
Fax number: ________________________________
Date: ______________________________________
THIS SECTION TO BE COMPLETED BY THE MACC, CBOSS, OR DYFS DISTRICT OFFICE AS
CONFIRMATION OF ELIGIBILITY
12.
Medicaid eligibility effective date: ___________________
Termination date: ___________________________________________
13.
Medicaid/NJ FamilyCare Eligibility Information Number (if not entered
above):
_____________________________________________________________
14.
Attach copy of computer screen showing effective date and termination
date of "Special Program Code 15"
Note: Hospice eligibility dates correspond to election or revocation
dates.
Contact person and telephone number: _______________________________________
Date: __________________________________
Agency: ____________________________________________________________________
FD-383 (05/04)
INSTRUCTIONS FOR SUBMITTING THE HOSPICE
ELIGIBILITY FORM (FD-383)
The Hospice Eligibility Form (FD-383) is to be initiated by the hospice
provider. The purpose of this form is to notify the MACC, CBOSS or DYFS
District Offices that hospice services have been selected. It verifies that
the beneficiary is medically eligible for Medicaid/NJ FamilyCare fee-for-
service hospice services and that the process for determining financial
eligibility has been initiated. The form is used by the MACC, CBOSS or DYFS
District Offices to identify a hospice beneficiary with the entry of Special
Program Status Code 15 into the data system. Accurate completion of this form
is necessary in order to receive reimbursement payment for hospice services
provided to Medicaid/NJ FamilyCare fee-for-service beneficiaries for
specific dates of service. This form is not completed for Medicaid managed
care beneficiaries.
Form FD 383 must be completed by the hospice provider when hospice services
are elected, revoked or the Medicaid/NJ FamilyCare beneficiary dies. If there
is a change in hospice providers or a change in the Medicaid/NJ FamilyCare
beneficiary's address, this form is used to reflect those changes.
The first section of form FD-383 must be completed by the hospice provider.
Blocks one through eleven should reflect current demographic information
regarding the hospice beneficiary and also applicable dates of election of
services, physician certification, termination, revocation or death. The
hospice name and provider billing number must be included with a signature,
phone and fax number and a date in order to certify and validate the
information. Absence of a dated signature of the hospice provider invalidates
the information, and the FD-383 form should be returned to the hospice
provider for completion.
The hospice provider must send the original copy of form FD-383 with the
Physician's Certification/Recertification form (FD-385) and the Election of
Hospice Benefits form (FD-378) to the agencies as follows:
-- To the Medical Assistance Customer Center (MACC) for SSI eligibles
-- To the County Boards of Social Services (CBOSS) of the beneficiary's
residence for Medicaid Only and New Jersey Care...Special Programs
applicants
-- To the Division of Youth and Family Services (DYFS) District office
for children in DYFS foster care
The MACC, CBOSS or DYFS District Office will process the data and return a
copy of form FD-383 to the hospice provider with a copy of the computer
screen showing the effective date and termination date of Special Program
Status Code 15.
FORM # 7
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
CHANGE OF HOSPICE
I, _________________________________________________________________________
(Beneficiary's Name and Medicaid/NJ FamilyCare Eligibility Identification
Number)
wish to change the designation of the particular hospice from which I
receive hospice care. I no longer wish to receive hospice service from:
___________________________________________________________________________,
(Hospice Agency and Medicaid Provider Billing Number)
but instead wish to receive services from:
____________________________________________________________________________
(Hospice Agency and Medicaid Provider Billing Number)
effective this ______________________________ day of __________, 20____.
I understand that this change of hospice providers is not a revocation of
the remainder of this election period.
___________________________________ __________________________________
Beneficiary's Signature or Mark Witness Signature
___________________________________ __________________________________
Date Date
FD-384 (05/04)
FORM # 8
STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
PHYSICIAN'S CERTIFICATION/RECERTIFICATION
FOR HOSPICE BENEFITS FORM
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)
FORM #9
NOTIFICATION FROM LONG-TERM CARE FACILITY
OF ADMISSION OR TERMINATION OF A MEDICAID PATIENT
I. PATIENT INFORMATION
1. Name: ____________________
2. Social Security No.:____-___-____
3. HSP (Medicaid) Case No.: ____ - ___
Confirmed By: ______________ [ ]
Medicaid Only
(CWA) [ ] SSI
4. Authorized By: ________________
LTCFO
Date of Birth: ____ /____ /____
5. Sex: [ ] Female [ ] Male
___________________________________________________________________
II. PROVIDER INFORMATION
1. Provider Number: ____ ____ ____ ____ ____ ____ ____ ____
2. LTCF Name: ________________________
5. Long Term Care Field Office
_______________
3. Address: _____________________ LTCFO Street Address: ___________________
4. City, State, Zip:
___________________________________________________________________________
___________________________________________________________________________
III. ADMISSION INFORMATION
1. Admission Date: ____ /____ /____
2. Admitted to Room Number: _____________ Bed Number: ______________
3. Admitted from: [ ] Community/Boarding Home [ ] Medicare to Medicaid
[ ] Psychiatric Hospital
[ ] Private to Medicaid - anticipated Medicaid effective date: ___/___/___
[ ] Hospital [ ] Other LTCF [ ] Other (specify): _______________________
4. Name of Hospital/LTCF: __________________ Admission Date: ____ /____ /____
Address: ___________________________________________________________________
____________________________________________________________________________
5. If admitted from Hospital/LTCF, give the name/address of previous
residence (Hospital Name and Address or Home Address):
____________________________________________________________________________
____________________________________________________________________________
IV. TERMINATION INFORMATION
1. Discharge Date: ____ /____ /____
2. Discharge to: [ ] Own Home (check one): [ ] With Medicaid Services or
[ ] Without Medicaid Services
[ ] Relative's Home (check one): [ ] With Medicaid Services or
[ ] Without Medicaid Services [ ] Assisted Living (Name/County):
__________________________________________________________
[ ] Other LTCF (Name/County):
__________________________________________________________
[ ] Other (specify):
__________________________________________________________
Telephone Number of Discharge Site ________________________________
3. Death (Date): ____ /____ /____ [ ] In LTCF [ ] In Hospital
____________________________________________________________________________
____________________________________________________________________________
V. CERTIFICATION
The facility certifies that the patient will reside only in those areas of
the facility which are certified for participation in the New Jersey Medicaid
Program at the level of care authorized for this patient by the New Jersey
Medicaid Program. The facility also certifies that upon discharge to a
hospital, the patient's room/bed will be reserved for the full period of
time covered by the New Jersey Medicaid Bed Reserved Policy.
This form completed by:
Name: _______________________________________________
Title: __________________________________________ Date:_____________________
____________________________________________________________________________
VI. CWA USE ONLY
Medicaid Effective Date: ____ /____ /____
[ ] Medicaid ONLY (PA-3L Attached)
[ ]SSI Only (PA-3L Required, Contact DHSS) COUNTY WELFARE OFFICE
____________________
[ ] Not Eligible
Street Address:
_____________________________________
[ ] Transcript Requested - Date: ___/___/___ City and Zip: __________
Remarks: ___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Name of Case Worker: ______________________________ Date: __________________
____________________________________________________________________________
LTC-2 MAR 03 Original-CWA Copy-LTCFO Copy-Provider
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