New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 3 - BENEFICIARY REQUIREMENTS › Section 10:53A-3.2 - Application procedure for medical and financial eligibility for hospice services

Current through Register Vol. 56, No. 14, July 15, 2024
(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.