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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-01010 (10/08) STATE OF WISCONSIN DHS 107.31(2)(b), Wis. Admin. Code WISCONSIN MEDICAID HOSPICE BENEFIT REVOCATION

How to fill out wisconsin medicaid hospice benefit

How to fill out Wisconsin Medicaid Hospice Benefit:

Gather necessary documentation:

1. Obtain the Wisconsin Medicaid Hospice Benefit application form.
2. Gather all personal identification documents, such as proof of residency, social security number, and birth certificate.
3. Collect all necessary medical records, including a statement from the attending physician certifying that the individual is terminally ill and has a life expectancy of six months or less if the illness runs its natural course.

Complete the application form:

1. Carefully fill out all required sections of the Wisconsin Medicaid Hospice Benefit application form.
2. Provide accurate and up-to-date information about the applicant's personal details, including name, address, date of birth, and social security number.
3. Answer all questions regarding the applicant's medical condition, including the diagnosis and prognosis.

Attach supporting documents:

1. Ensure you have all required supporting documents to accompany the application form.
2. Include the statement from the attending physician certifying the individual's terminal illness and life expectancy.
3. Attach any additional medical records that may support the application and eligibility for the Wisconsin Medicaid Hospice Benefit.

Submit the application:

1. Once you have completed the application form and gathered all necessary supporting documents, submit them to the appropriate Wisconsin Medicaid office.
2. Follow the provided instructions on where to send the application form and supporting documents.
3. It is recommended to keep copies of all submitted documents for your records.

Who needs Wisconsin Medicaid Hospice Benefit:

Individuals with a terminal illness:

1. The Wisconsin Medicaid Hospice Benefit is designed for individuals who have been diagnosed with a terminal illness.
2. This benefit provides support and coverage for various medical services and care required during the final stages of a person's life.

Individuals with a life expectancy of six months or less:

1. To be eligible for the Wisconsin Medicaid Hospice Benefit, the individual must have a life expectancy of six months or less if the illness runs its natural course.
2. This requirement ensures that the benefit is directed towards individuals who truly need end-of-life care and support.

Individuals who meet the financial eligibility criteria:

1. Applicants must meet the financial eligibility criteria set by Wisconsin Medicaid to qualify for the Hospice Benefit.
2. This typically involves meeting specific income and asset limits determined by the state.

Overall, the Wisconsin Medicaid Hospice Benefit is intended for individuals with a terminal illness and a life expectancy of six months or less, providing them with comprehensive medical services and support during their final stages of life.

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