Hospice: Application for State Licensure and Federal Certification

Follow these steps if your hospice chooses to seek state licensure and Medicare certification simultaneously using a state and federally-approved accrediting organization:

Step 1: Contact an outside accrediting organization

The following accrediting organizations are approved to provide this combined survey process. Contact one of them and tell them you would like to seek simultaneous Wisconsin state licensure and Medicare certification. Additional fees may apply when using one of these organizations:

• Accreditation Commission for Health Care (ACHC)
• Community Health Accreditation Partners (CHAP)
• The Joint Commission (TJC)

Once your hospice agency has successfully enrolled in an accrediting organization's program, they will provide you with a letter of acceptance.

Step 2: Apply for provisional licensure

Send the following to DQA:

• Letter of acceptance from your chosen accrediting agency (see step 1).
• Letter of intent with a detailed description of the proposed hospice.
• Completed Wisconsin Hospice License Application, F-62062 (Word)
• Credentials including resumes and licenses that demonstrate that the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 131.29 for details.
• Hospice application fee ($300), payable to the Division of Quality Assurance.
• Background Check Program completed online. Include fees ($15 per individual).
• Organizational chart, including any other entities owned by the proposed hospice.
• Financial references showing your hospice has the funding or revenue necessary to continue operating the business during provisional licensure, which could include:
  • Letter of reference from the hospice's financial institution.
  • Bank statement.
  • Evidence of stock ownership.
• Copy of the Internal Revenue Service's letter showing your Employer Identification Number.
• Organizational documents depending on your hospice structure:
  • Corporations: Provide a copy of articles of incorporation.
  • Limited liability companies (LLCs): Provide a copy of articles of organization and operation agreement.
  • Limited liability partnerships (LLPs): Provide a copy of the partnership agreement.

You should also submit the following to your chosen accrediting organization at this time:

• Policies and Procedures: Demonstrate, via submission of the hospice agency's policies and procedures and patient care documentation, your compliance with Wis. Admin. Code ch. DHS 131 for hospices. Also demonstrate via submission of agency policies and procedures, your compliance with Wis. Admin. Code ch. DHS 13 Reporting and Investigation of Caregiver Misconduct. Refer to Chapter 6 of the Wisconsin Caregiver Program Manual, P-00038 (PDF).
• A copy of the same Wisconsin Hospice License Application, F-62062 (Word) submitted to DQA.

Step 3: Your accreditation agency reviews your application

• Once all required materials mentioned previously are received, DQA will perform a fit and qualified review of the applicant under Wis, Admin. Code ch. DHS 131. If no issues are found during this review, DQA will send a letter to the prospective hospice and their chosen accrediting organization. This triggers the accrediting organization to conduct a provisional licensure survey.
• The accrediting organization will then perform a provisional licensure survey. Once that survey process is complete, the accrediting organization will inform the state and a provisional hospice license will be issued.

Step 4: Operating a hospice under a provisional license

The now-provisional hospice can begin serving clients. Note that the hospice is still not Medicare or Medicaid certified, so those funding sources will not be available during this period.

The accrediting organization will approve the prospective hospice for one year of provisional accreditation. DQA will then grant provisional state licensure with the same effective date. The goal of this provisional licensing period is to serve five clients that require skilled nursing services (including three active clients).

Step 5: Medicare certification documents

Also during this provisional licensure period, begin submitting required Medicare certification documents to DQA, including:

• CMS-855 Medicare Enrollment Application (PDF) submitted to Wisconsin's Medicare Administrative Contractor, currently National Government Services (NGS). Once the administrative contractor has approved this form, they'll send a copy to DQA. Please also provide a copy of this CMS-855 approval letter to your accrediting agency. They will need this document before performing your final initial Medicare certification and licensure survey.
• A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.
• A screenshot or copy of the confirmation page from CMS's Office of Civil Rights Assurance of Compliance process.

Step 6: Accrediting organization permanent licensure and Medicare certification survey

Once the hospice has served five patients requiring skilled nursing care, the hospice should send a letter, along with five patient care plans, to their chosen accrediting organization. This will trigger the accrediting organization to perform an on-site unannounced survey toward state hospice licensure requirements and the Medicare Conditions of Participation.

Step 7: Permanent hospice licensure and Medicare certification

Once the accrediting organization's initial Medicare Certification survey process is complete, including any required corrections, a permanent hospice license can be issued.

If DQA has received all federal certification documents mentioned in step 3, DQA can also recommend Medicare certification to CMS at this time. CMS will ultimately be responsible for approving or denying the recommendation and issuing a Medicare number.

Follow this process if your hospice chooses to seek state licensure and Medicare certification simultaneously through a state agency survey process:

Step 1: Apply for provisional licensure

Send the following to DQA:

• Letter of intent with a detailed description of the proposed hospice.
• Completed Wisconsin Hospice License Application, F-62062 (Word)
• Credentials including resumes and licenses that demonstrate that the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 131.29 for details.
• hospice application fee ($300), payable to the Division of Quality Assurance.
• Background Check Program completed online. Include fees ($15 per individual).
• Organizational chart, including any other entities owned by the proposed hospice.
• Financial references showing your hospice has the funding or revenue necessary to continue operating the business during provisional licensure, which could include:
  • Letter of reference from hospice's financial institution.
  • Bank statement.
  • Evidence of stock ownership.
• Copy of the Internal Revenue Service's letter showing your Employer Identification Number.
• Organizational documents depending on your hospice structure:
  • Corporations: Provide a copy of articles of incorporation.
  • Limited liability companies (LLCs): Provide a copy of the articles of organization and operation agreement.
  • Limited liability partnerships (LLPs): Provide a copy of the partnership agreement.
• Policies and Procedures: Demonstrate, via submission of agency policies and procedures and patient care documentation, your compliance with Wis. Admin. Code ch. DHS 131 for hospices. Also, demonstrate via submission of the hospice agency's policies and procedures, your compliance with Wis. Admin. Code ch. DHS 13 Reporting and Investigation of Caregiver Misconduct. Refer to Chapter 6 of the Wisconsin Caregiver Program Manual, P-00038 (PDF).

Once all required materials are received, DQA will have up to 90 days to review your application materials, including a detailed review of your hospice's policies and procedures. Upon completion of that review, DQA will issue a provisional hospice license that is good for two years. The goal of this provisional licensing period is to serve five clients that require skilled nursing services.

Step 2: Operating a hospice under a provisional license

The now-provisional hospice can begin serving clients. Note that the hospice is still not Medicare or Medicaid certified, so those funding sources will not be available during this period.

Once the hospice has served five clients requiring skilled nursing care, send a letter, along with five patient care plans, to DQA. This will trigger DQA to perform an on-site unannounced survey toward state hospice licensure requirements and the Medicare Conditions of Participation.

Step 3: Medicare certification documents

Also during this provisional licensure period, begin submitting required Medicare certification documents to DQA, including:

• CMS-855 Medicare Enrollment Application (PDF) submitted to Wisconsin's Medicare administrative contractor, currently National Government Services (NGS). Once the administrative contractor has approved this form, they will send a copy to DQA.
• A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.
• A screenshot or copy of the confirmation page from CMS's Office of Civil Rights Assurance of Compliance process.

Step 4: DQA Survey

Once DQA has received the hospice's five patient care plans, as mentioned in step 2, DQA surveyors will perform an unannounced on-site survey toward state hospice regulations and the Medicare Conditions of Participation. If any issues are identified during that survey, a plan of correction will need to be submitted.

Step 5: Permanent hospice licensure and Medicare certification

Once DQA's onsite survey process is complete, including any required corrections, a permanent hospice license can be issued.

If DQA has received all federal certification documents mentioned in step 3, DQA will recommend Medicare certification to CMS at that time. CMS will ultimately be responsible for approving or denying the recommendation and issuing a Medicare number.

Note that state licensure should be completed at the same time or before Medicare or Medicaid certification. State licensure does not guarantee Medicare certification.

As a prospective hospice, you must complete an application, pay fees, and submit supporting documentation that demonstrates your compliance with Wis. Admin. Code ch. DHS 131 before receiving a license.

Send the following to DQA:

• Letter of intent with a detailed description of the proposed hospice. Include credentials to show the administrator and substitute administrator meet position requirements. See Wis. Admin. Code § DHS 131.29 for details.
• Completed Wisconsin Hospice License Application, F-62062 (Word).
• Hospice application fee ($300).
• Background Check Program completed online. Includes a fee of $15 per individual.
• Organizational chart, including any other entities owned by the proposed hospice.
• Financial references, which could include:
  • Letter of reference from the hospice's financial institution.
  • Bank statement.
  • Evidence of stock ownership.
  • Verification of outside employment or other income.
• Copy of the Internal Revenue Service's letter with your Employer Identification Number.
• Organizational documents depending on your hospice's structure:
  • Corporations: Provide a copy of articles of incorporation.
  • Limited liability companies (LLCs): Provide a copy of articles of organization and operation agreement.
  • Limited liability partnerships (LLPs): Provide a copy of the partnership agreement.
• Policies and procedures. Demonstrate compliance with:
  • Wisconsin Admin. Code ch. DHS 131.
  • Wisconsin Admin. Code ch. DHS 13 (refer to Chapter 6 of the Wisconsin Caregiver Program Manual, P-00038 (PDF)).

Wisconsin has a two-step application review process once DQA receives all materials. The first review determines whether an applicant is fit and qualified according to the statute. It includes a review of factors like:

• Financial solvency.
• Personnel qualifications.
• Criminal background clearance.
• Payment of required fees.
• History of operating health care agencies in other states.
• Documentation that shows the provision of skilled nursing and therapeutic services to patients in their homes.

Once DQA deems a prospective hospice fit and qualified, a registered nurse will review policies and procedures to determine whether they meet Wisconsin codes.

Once approved, DQA will grant provisional state licensure. This provisional licensure is good for two years.

As a provisional hospice, you can begin serving clients.

Once you have served five clients with skilled nursing care (including three active clients), send a letter and the patient care plans to DQA. State surveyors will then conduct an unannounced Wisconsin licensure survey. Once the survey is complete, including any necessary corrections, DQA can grant permanent hospice licensure.

If an applicant intends to seek both Wisconsin hospice licensure and Medicare/Medicaid certification, DQA advises following one of the streamlined processes in the "Simultaneous state licensure and Medicare certification via accrediting organization" or "Simultaneous state licensure and Medicare certification via state agency survey" accordions rather than completing licensure and Medicare certification separately.

State licensure does not guarantee Medicare or Medicaid certification.

If an already-licensed hospice would like to seek Medicare certification, provide the state with the following:

• CMS-855 Medicare Enrollment Application (PDF) submitted to Wisconsin's Medicare Administrative Contractor, currently National Government Services (NGS). Once the administrative contractor has approved this form, they'll send a copy to DQA. Also provide a copy of this CMS-855 approval letter to your accrediting agency. They will need this document before performing your final Medicare certification and licensure survey.
• A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.
• A screenshot or copy of the confirmation page from CMS's Office of Civil Rights Assurance of Compliance process.
• A copy of your full survey report from your Medicare certification survey. This survey can either be performed by state agency surveyors or by one of these federally-approved accreditation organizations:
  • Accreditation Commission for Health Care (ACHC)
  • Community Health Accreditation Partners (CHAP)
  • The Joint Commission (TJC)

Once DQA has received all federal certification documents, they can recommend Medicare certification to CMS. CMS will ultimately be responsible for approving or denying the recommendation and issuing a Medicare number.

To become Medicaid certified, a hospice must first meet state licensing requirements and obtain a provisional license.

If you're interested in becoming a Wisconsin Medical Assistance (Medicaid) Program certified provider, DQA recommends applying while you apply to Medicare. See Wisconsin Medicaid provider certification on ForwardHealth.

Learn more from these Medicaid Contacts.

You must contact DQA if your existing hospice is undergoing a:

• Name change.
• Address change.
• Administrator change.
• Accreditation status change.
• Change of ownership (CHOW).
• Change of ownership information (CHOI).

You may contact a licensing specialist directly. Call 608-266-7297 or email dhsdqalccs@dhs.wisconsin.gov.

Note: If the hospice operation is transferred to another owner, ownership group, or lessee, the Health Insurance Benefits Agreement will be transferred. You are required to notify DQA when are planning a change of ownership, since your license is non-transferable. DQA will provide instructions regarding this process.

You may find the following forms useful in conducting an agency self-evaluation of compliance with Wisconsin administrative rules. Surveyors use these forms during on-site state licensure surveys.

• Hospice Inpatient Care, F-62641 (Word)
• Hospice Contracts and Agreements Review, F-62232 (Word)
• Hospice Inpatient Clinical Record Review - Interviews, F-62322 (Word)
• Hospice Inpatient Facility Plan Review, F-62333 (Word)
• Hospice Patient Rights, F-62316 (Word)
• Hospice Personnel Record Review, F-62233 (Word)
• Hospice Quality Assessment and Performance Improvement Review, F-62318 (PDF)
• Hospice Survey Information, F-62320 (Word)
• Hospice Volunteer Program Review, F-62319 (Word)