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Medicaid streamlines process for election of the hospice benefit

In an effort to streamline the hospice-election process and reduce unnecessary burdens on beneficiaries and providers, the Mississippi Division of Medicaid (DOM) has updated and simplified the notification forms for the election of the hospice benefit. Please see the specifics listed below of both the updated requirement of dually eligible beneficiaries along with changes to hospice forms. These updates will be effective March 1, 2021.

Update to the Administrative Code Update: Part 205, Chapter 1, Rule 1.10 – For dual eligible beneficiaries, DOM requires the hospice provider to notify DOM’s Utilization Management/Quality Improvement Organization (UM/QIO), Alliant Health Solutions, within five (5) calendar days of the beneficiary’s hospice election or discharge date. Please refer to Alliant Health Solutions’ provider portal at:, or call Alliant directly at 1-888-224-3067, for assistance from the UM/QIO.

Updates to the following Hospice Forms are located on DOM’s website at These forms must be used effective March 1, 2021.

New Notice of Hospice Election or Discharge for Dual Eligible Beneficiaries – This new form is required to notify DOM of a hospice election for dual eligible beneficiaries. The following forms will no longer be required for dual eligible beneficiaries:

      • Election Notice Form (1165 A-B),
      • Hospice Discharge/Hospice Revocation Form (1166 A)
      • Physician Certification/Recertification of Terminal Illness (1165 C)

Update to the Hospice Discharge/Hospice Revocation Form – This updated form should be used for Medicaid-only beneficiaries. This form now only requires the beneficiary’s signature on the hospice revocation statement. A hospice discharge does not require the beneficiary’s signature.

Updates to the Election Notice Form – This updated form should be used for Medicaid-only beneficiaries. Updates include the following:

    • Removed the “to-from” election period date and now requires only the election date.
    • Added the county where hospice services will be provided.
    • Clarified the choice of having or not having an attending physician to oversee a beneficiary’s hospice care.

    If you have any questions please contact the Office of Long Term Care at (601) 359-6141.

    Published Feb. 10. 2021