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Wisconsin Hospice Application Process

Hospices must be licensed in Wisconsin prior to obtaining Medicare or Medicaid certification.

NOTE TO APPLICANTS: Initial Surveys for Medicare Participation: S&C Memo 08-03: Initial Surveys for New Medicare Providers (exit DHS)

The issuance of a state license to operate a hospice in Wisconsin is separate from the Medicare provider enrollment and certification process.

THE FEDERAL MEDICARE CERTIFICATION PROCESS MAY TAKE A YEAR TO COMPLETE

State Licensure

Application 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:  

  1. You must complete an application which may be obtained from the Hospice Licensing Specialist who can be reached at 608-266-2702.

  2. Demonstrate compliance with Caregiver Background Check Process

  3. Demonstrate compliance with WI Stats., Chp 50.09(2) Licensing Requirement for fit and qualified

  4. Submit required application fees

  5. Demonstrate, via submission of policy/procedures and patient care documentation, compliance with WI Administrative Rule requirements: DHS 131 – Hospice 

  6. Demonstrate, via submission of policies/procedures compliance with WI Administrative Rule DHS 13: Reporting and Investigation of Caregiver Misconduct. Refer to Chapter 6 of the Wisconsin Caregiver Program Manual (PDF, 24 KB)

Issuance of Provisional License:

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: 

  • Core services provided by the licensee cannot be administered by contracted staff.  Each member of the core team must be an employee or volunteer of the hospice.  Hospice core team members must directly furnish all of the following services pursuant to DHS 131.25, Wisconsin Administrative Rule:

  1. Nursing care by a registered nurse

  2. Medical Services – A medical director who is a medical doctor or a doctor of osteopathy

  3. Social Services – Based on qualifications of DHS 131.25(5)

  4. Bereavement 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 DHS 131 and DHS 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.

NOTE:  If seeking Medicare certification, you must request application materials and take measures to assure compliance with all Medicare Conditions of Participation.     

Regular License and Medicare Certification Process:

Before expiration of the 24-month provisional license, the hospice licensee must receive an on-site survey by the Division of 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: 

  • Admitted at least 5 patients; 3 must be active patients at the time of survey.

  • Provide 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.

  • Hired all required personnel and each has been fully oriented to their job responsibilities.  

  • Provide signed copies of all required contracts.

  • Provide 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 Department.

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.

Residential 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.  DHS 131, Subchapter V – Physical Environment outlines the requirements.  These provisions apply to all new, remodeled and existing construction unless otherwise noted.

You will be required to submit a plan review to the Department for approval before construction is started:

  1. A copy of the preliminary or schematic plan

  2. A 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 following:

Hospice 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:

  1. Nursing care by or under the supervision of a registered nurse

  2. Medical Social Services by a qualified social worker under the direction of a physician

  3. Physician Services

  4. Counseling, including, but not limited to bereavement, spiritual and dietary counseling

B. The following services may be provided either directly or under arrangement by the hospice:

  1. Physical therapy, occupational therapy, speech-language pathology and dietary services

  2. Services of a home-health aide who successfully completed a training program approved by the Secretary

  3. Medical supplies and the use of medical appliances

  4. Short term inpatient care

  5. Homemaker/Companion services

Federal Forms - Complete and submit:

  • CMS 417 - Hospice Request For Certification in the Medicare Program (exit DHS; PDF 445 KB)

  • Submit two copies of Health Insurance Benefit Agreement (CMS-1561) (exit DHS; PDF 426 KB)

    • The person signing the Health Insurance Benefits Agreement (CMS 1561) must be someone who has the authorization of the owners of the agency to enter into this agreement.

  • Office for Civil Rights forms; Hard copies or complete/submit On line (exit DHS):

    • Data Request Checklist-Civil Rights Information Request

    • HHS 690- Assurance of Compliance form (two signed copies if completing hard copies)

  • Contact your Fiscal Intermediary to have a Medicare General Enrollment Health Care Provider/Supplier Application (CMS- 855A) completed and submitted.

  • This separate enrollment requirement must precede survey and certification.

    • In Wisconsin, the fiscal intermediary is National Government Services (exit DHS) in Milwaukee unless your facility is affiliated with a CMS-designated chain, in which case, it may have a designated single U.S. fiscal intermediary.

All forms should be submitted to:

Department of Health Services
Division of Quality Assurance
Hospice Licensing Specialist
PO Box 2969
Madison, WI 53701-2969

(Ignore any other send-to addresses on the federal forms.)

Survey Process

State Licensure:

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 DHS 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.

Medicare Certification:

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 this:

  • 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 DHS 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 program.

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. See Wisconsin Medicaid provider certification packets on the Wisconsin ForwardHealth website

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.

Licensee 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 is non-transferable.

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.

  • You are required to notify the Division of Quality Assurance at the time you are planning a change-of-ownership transfer as your license is non-transferable.

  • Complete all applicable sections of application, including Section B. which may be obtained from the Hospice Licensing Specialist who can be reached at 608-266-2702

See Rules & Regulations for hospices:

  • Wisconsin Statutes, Chapter 50.90

  • Wisconsin Administrative Code, DHS 131 - Hospice Rules

  • Please review and submit Policies and Procedures Necessary to meet DHS 131

  • A nonrefundable fee of $300.00 must be included with your application as required under DHS 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 request.

    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
Division of Quality Assurance
Hospice Licensing Specialist
PO Box 2969
Madison, WI 53701-2969

 

Last Revised: August 04, 2014