Hospice: Application for State Licensure and Federal Certification

The following accrediting organizations are approved to provide this combined survey process:

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

Follow this process for the combined application:

1. Choose and contact an accrediting organization. This organization should provide a letter stating the prospective hospice has been accepted into the survey program.
2. Send the following to DQA:
   • Letter of acceptance from your chosen accrediting agency.
   • Letter of intent with a detailed description of the proposed hospice. Include credentials to show the administrator and substitute administrator meet position requirements. For details, see Wis. Admin. Code § DHS 131.29.
   • 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 specific to your hospice's structure:
     • Corporations—Provide a copy of articles of incorporation.
     • Limited liability companies—Provide a copy of articles of organization and operation agreement.
     • Limited liability partnerships—Provide a copy of the partnership agreement.
3. Submit a copy of your Wisconsin Hospice License Application, F-62062 (Word) to your accrediting organization. Also include all agency policies and procedures.
4. DQA will send a letter to the prospective hospice and the accrediting organization once the application is approved. This will trigger the accrediting organization to conduct a provisional licensure survey.
5. 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 now-provisional hospice can begin serving clients.

Once you have served five clients with skilled nursing care (including three active clients), send a letter and 10 patient care plans to DQA and the accrediting organization. The accrediting organization will start a combined unannounced Wisconsin licensure and Medicare certification survey. The accrediting organization will notify the hospice and DQA once the survey is complete and the hospice is approved.

During the provisional licensure period, begin submitting required Medicare certification documents, including:

• CMS-855 Medicare Enrollment Application (PDF) submitted to Wisconsin's assigned Medicare Administrative Contractor, which is currently National Government Services. Once the contractor has approved this form, they will 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 certification and licensure survey.
• A signed CMS-1561 Health Insurance Benefits Agreement (PDF) submitted to DQA.

Once DQA has these documents and the accreditation organization survey, it can issue permanent state licensure and recommend Medicare certification to CMS.

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—Provide a copy of articles of organization and operation agreement.
  • Limited liability partnerships—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 you're applying for an optional Medicare certification, DQA advises submitting application materials and supporting documentation at the same time as your Wisconsin state licensure.

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

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

To obtain Medicare certification:

1. Review the following CMS Medicare information for hospices:
   • Federal Conditions of Participation for Hospice Care, 42 CFR 418.
   • SOM Appendix M – Guidance to Surveyors: Hospice Agencies (PDF).
2. Complete CMS-855 Medicare Enrollment Application (PDF) and submit it to Wisconsin's assigned Medicare Administrative Contractor, which is currently National Government Services. Once the contractor has approved this form, they will 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 certification and licensure survey.
3. Contact a CMS Approved Accrediting Organization (PDF) to perform the Medicare Certification survey (this step is separate from the Wisconsin state licensure survey).
4. Submit a signed CMS-1561 Health Insurance Benefits Agreement (PDF) to DQA.

Once DQA has issued your hospice license and has copies of the above, DQA will provide these documents to CMS and recommend Medicare certification approval.

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)