Wisconsin Hospice Application
Hospices must be licensed
in Wisconsin prior to obtaining Medicare or Medicaid certification.
TO APPLICANTS: INITIAL SURVEYS FOR MEDICARE PARTICIPATION: S&C Memo
08-03: Initial Surveys for New Medicare Providers (PDF,
The issuance of a state license to operate a hospice
in Wisconsin is separate from the Medicare provider enrollment and certification
THE FEDERAL MEDICARE CERTIFICATION PROCESS MAY A YEAR
for Provisional License:
As a hospice applicant, you are required to complete
an application, pay fees and submit supporting documentation in the
form of policies & procedures that will demonstrate your compliance
with Wisconsin regulatory requirements, including:
must complete an application which may be obtained from the
Hospice Licensing Specialist who can be reached at 608-266-2702.
compliance with Caregiver Background Check Process
compliance with WI Stats., Chp 50.09(2) Licensing Requirement for fit
required application fees
via submission of policy/procedures and patient care documentation,
compliance with WI Administrative Rule
requirements: HFS 131 –
via submission of policies/procedures compliance with WI
Administrative Rule HFS 13: Reporting and Investigation of Caregiver
Wisconsin has a two-tier provisional license application review process.
The first review determines whether an applicant is fit and
qualified, and includes an analysis of a variety of factors; financial
solvency, personnel qualifications; including criminal background checks,
payment of required fees, if applicable, history of operating a hospice in
other states, and documentation that demonstrates the provision of the
following required hospice services:
care by a registered nurse
Services – A medical director who is a medical doctor or a
doctor of osteopathy
Services – Based on qualifications of HFS 131.25(5)
services by qualified individuals
Following a determination of whether the applicant is
fit and qualified, the second tier review is completed by a Registered
Nurse (RN) who will review the applicant’s copies of policies and
procedures to determine whether they meet administrative rule requirements
of HFS 131 and HFS
13. The RN
will consult with the applicant during this review.
When tier one and tier two reviews are complete and satisfy code
requirements, a 2-year provisional license will be recommended.
seeking Medicare certification, you must request application materials and
take measures to assure compliance with all Medicare Conditions of
License and Medicare Certification Process:
Before expiration of the 24-month provisional
license, the hospice licensee must receive an on-site survey by the
Quality Assurance to determine compliance with all WI Administrative rule
requirements. If not, the
provisional license automatically expires and the licensee is required to
discharge all patients from service.
At this survey, the Division of Quality Assurance will
evaluate the licensee’s compliance with the Medicare Conditions of
Participation for Hospice. This
assumes the licensee has made appropriate application for Medicare
certification and has received notice of federal fiscal intermediary
clearance (CMS 855).
Before an unannounced survey is scheduled, the
licensee must provide a written request for the on-site survey and provide
written evidence that demonstrates you meet the following criteria:
at least 5 patients; 3 must be active patients at the time of survey.
evidence that licensee will provide services to patients residing in
their homes and not limited to patients residing in nursing homes,
CBRFs, assisted living facilities or inpatient facilities.
all required personnel and each has been fully oriented to their job
signed copies of all required contracts.
copies of 3 patient care plans; including the patient’s initial plan
of care, and subsequent integrated plans of care.
The written request for the on-site survey; including
submission of the above documents, must be sent to: Hospice Licensing Specialist,
Division of Quality Assurance, Post Office
Box 2969, Madison, WI 53701-2969.
Upon successful completion of the on-site survey, and
a determination made whether the licensee is in substantial compliance
with the administrative rules, a regular, non-expiring license will be
issued. This regular license
will remain in effect unless voluntarily surrendered by the licensee, a
change of owner occurs, or the license is revoked or suspended by the
The results of the initial Medicare certification
survey will be forwarded to the Centers for Medicare/Medicaid Services
(CMS) with a recommendation regarding certification.
CMS will notify the licensee of their effective date of
participation in the Medicare program.
Free-Standing Hospice and/or Freestanding Inpatient Facility
Wisconsin Administrative Rule addresses the physical
plant requirements for a hospice facility that will serve three or more
patients not located in a licensed hospital or nursing home.
HFS 131, Subchapter V – Physical Environment outlines the
requirements. These provisions
apply to all new, remodeled and existing construction unless otherwise
You will be required to submit a plan review to the
Department for approval before
construction is started:
copy of the preliminary or schematic plan
copy of the final plans and specifications
Please visit Plan Review for HealthCare Facilities
Medicare Certification (Optional)
In order to become certified in the Medicare Program, an agency must
first meet State of Wisconsin licensing requirements
and obtain a provisional license. The hospice must also meet the
Information Resource for Medicare (exit DHS)
42 CFR 418, Hospice Conditions of Participation, Code
of Federal Regulations (exit DHS)
Medicare Definition of Hospice:
- Hospices limiting their scope of services to treating only patients
in residential facilities do not meet the definition of hospice as
defined by Medicare.
- Section 1861(dd)(2)(A)(ii) of the Social Security Act defines a
hospice program as a public agency or private organization which
provides for such care and services in individuals' homes, on an
outpatient basis, and on a short-term inpatient basis.
- Entities that only provide hospice services to their residents and
exclude outpatients do not meet this definition and may not
participate in the Medicare program as a hospice.
- This determination may also apply to hospices serving patients only
in residential facilities which are not owned directly by the hospice.
Hospice care is an essential Medicare benefit that focuses on the
patient and family, and special support to the dying.
Medicare is committed to ensuring that all beneficiaries receive
appropriate care tailored to their own needs at the end of life and that
they understand their rights and options.
It was not intended to limit services to a select group of people or to
place any barriers to the provision of care.
Core Services Requirements:
A. A Hospice must directly furnish all of the following:
- Nursing care by or under the supervision of a registered nurse
- Medical Social Services by a qualified social worker under the
direction of a physician
- Physician Services
- Counseling, including, but not limited to bereavement, spiritual and
B. The following services may be provided either directly or
under arrangement by the hospice:
- Physical therapy, occupational therapy, speech-language pathology
and dietary services
- Services of a home-health aide who successfully completed a training
program approved by the Secretary
- Medical supplies and the use of medical appliances
- Short term inpatient care
- Homemaker/Companion services
Federal Forms - Complete and submit:
All forms should be submitted to Department of Health
Services, Division of Quality
Assurance, Hospice Licensing Specialist, PO Box 2969,
Madison, WI 53701-2969.
A regular state licensure survey will be conducted at the same time as
the initial Medicare survey to ensure the agency is meeting the
requirements in Wisconsin Administrative Code HFS 131.
If it is determined that all requirements have been met, a non-expiring
regular state license will be issued. The license will remain in effect
unless voluntarily surrendered by the licensee, a change of owner occurs,
or the license is revoked or suspended by the Department.
An initial Medicare on-site survey will be performed by a surveyor, who
will inspect the facility, interview you and members of your staff, review
documents, and perform other procedures necessary to evaluate your
agency's compliance with the Conditions of Participation.
Full Operation Letter - Prepare and submit a written
notification once the hospice is in "full operation," i.e., the
agency has provided services to patients and has records to review. Do
- once the agency is operational
- has served at least five (5) patients
- at least three (3) patients remain active
- the CMS 855 enrollment application has been completed
- agency has been approved by the fiscal intermediary
Notice of anticipated date of full operation is not sufficient.
This notification is required in order to signal that your agency is
ready for a state and federal onsite survey to determine if all conditions
of participation and compliance with HFS 131 rules are met.
It is important to remember that a survey will not be
scheduled until the notification is received.
The notification should be sent to Department of Health Services, Hospice Licensing Specialist,
Division of Quality Assurance, Post Office
Box 2969, Madison, WI 53701-2969.
Following the survey, the Wisconsin Department of Health Services will recommend to the U.S. Department of Health and Human
Services (DHHS) whether the agency is to be certified in the Medicare
If denied Medicare approval, notification will be sent identifying the
reasons for denial, with information about rights to appeal the decision.
Medicaid Certification with the Wisconsin
Medical Assistance (Medicaid) Program (WMAP) - OPTIONAL
If you are interested in becoming a certified provider with the WMAP,
you are encouraged to apply at the same time that you apply to Medicare.
Medicaid provider certification packets on the Wisconsin
If the completed application for the WMAP is returned within thirty
(30) days of the date the blank application was mailed to the applicant,
the certification effective date with the WMAP will be the same as the
effective date with the Medicare program.
- Delays in applying to the WMAP may result in assignment of a later
certification effective date.
Application materials can be obtained by writing to EDS, Attention:
Provider Maintenance, 6406 Bridge Road, Madison, WI 53713, or by
calling 1-800-947-9627 (in-state toll free) or (608) 221-9883.
Change of Ownership:
If operation of the hospice is later transferred to
another owner, ownership group, or to a lessee, the licensee is required
to notify the Division of Quality Assurance at the time they are planning a
change-of-ownership transfer as the license
Documentation must be submitted to the Division of
Quality Assurance to officiate the change of owner.
If operation of the hospice
is later transferred to another owner, ownership group, or to a
lessee, the Health Insurance Benefits Agreement will be transferred.
See Rules & Regulations
Wisconsin Statutes, Chapter 50.90
Code, HFS 131 - Hospice Rules
Please review and submit
Policies and Procedures Necessary to
meet HFS 131
A nonrefundable fee
of $300.00 must be included with your application as required under
HFS 131.14(1), except that:
- The fee for a hospice that is a nonprofit corporation and
is served entirely by uncompensated volunteers or employs
persons in not more than 1.5 positions at 40 hours of employment
per week shall be $25; and
- The fee for a hospice that is a nonprofit organization,
that is served entirely by uncompensated volunteers and
that charges no fees may be waived by the department upon
Your check should be made payable to the Division
of Quality Assurance.
Caregiver Background Check Process - A caregiver background
check (CBC) is required to be completed for all applicants/legal
representatives prior to the approval of any new license,
certification or registration of a DQA regulated entity.
- Review information for Licensee Applicants/License Holder
Background Checks found on the
Caregiver Background Check Process web page for the completion
of the Background Information Disclosure (BID) form and Appendix.
Complete either the Online Caregiver Background Check (CBC) process
or the manual application process.
- Also review information on the requirement for Employee
Background Checks found on the
Caregiver Background Check Process web page.
The applications, fees, and forms should be sent to: Department
of Health Services, Hospice Licensing
Specialist, Division of Quality Assurance,
Post Office Box 2969, Madison, WI 53701-2969.
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April 04, 2013