Member Enrolled in hospice ? Does Medicare HMO covers the service?

What is Hospice?

Hospice is a program of care and support for people who are terminally ill.  It is available as a benefit under Medicare Hospital Insurance (Part A).  The focus of hospice is on care, not treatment or curing an illness.  Emphasis  is  placed  on  helping  people  who  are  terminally  ill  live  comfortably  by  providing comfort and relief from pain. Some important facts about hospice are:

** A  specially  trained  team  of  professionals  and  caregivers  provide  care  for  the  “whole  person”, including his or her physical, emotional, social and spiritual needs.

** Services may include physical care, counseling, drugs, equipment, and supplies for terminal illness and related condition(s).

** Care is generally provided in the home.
** Hospice isn’t only for people with cancer.
** Family caregivers can get support.

When all the requirements are met, the Medicare hospice benefit includes:

** Physician and nursing services
** Medical equipment and supplies
** Outpatient drugs or biological for pain relief and symptom management
** Hospice aide and homemaker services
** Physical, occupational and speech-language pathology therapy services
** Short term inpatient and respite care
** Social worker services
** Grief and loss counseling for the member and his or her family

When  a  member/patient  enrolled  in  hospice  receives  care  from  your  practice  or  facility,  it  is  very important that all of the care be coordinated with their hospice physician. Once a Member is enrolled in hospice, CarePlus Health Plans, Inc. (CarePlus) is not financially responsible for any services covered by Medicare regardless of whether the care is related to the hospice diagnosis or not, as long as the service provided is a Medicare covered benefit. CarePlus enrolls Hospice members into a new group effective the 1st of the month, following election of hospice, and removes them from the group at the end of the month, if the Member terminates or revokes the hospice benefit.  The Plan will continue to assist in coordination of the member’s care to the best of its ability, however, the payment process to providers changes.

For Hospice diagnosis related care, providers need to bill the  Medicare-approved hospice organization with which the patient is enrolled.  For care not related to the hospice related diagnosis, that is a Medicare covered benefit, providers need to bill the Fiscal Intermediary for CMS directly. If a Member’s hospice is revoked during a month, you must continue to bill the hospice organization or the Fiscal Intermediary for CMS through the end of that month.  CarePlus is only responsible for additional benefits not covered by Medicare, i.e. the transportation benefit. Any claims received by CarePlus for Medicare-covered services that are not additional plan benefits, will be denied by the Plan.

Note: A member who has elected hospice and requires medical treatment for a non-hospice condition can do one of the following:

(1) Use plan providers and services. In such a case, the member only pays plan allowed cost-sharing, and the provider would directly bill FFS for (Parts A and B services); or

(2) Use  non-network  providers  and  be  treated  under  FFS.  In  such  a  case,  if  the  service  is  not emergent/urgent care, the member would pay the total FFS allowed cost-sharing.

When hospice services are requested by a Member, confirmed with the Centers for Medicare & Medicaid  Services (CMS) and updated in the Plan’s system, the Member is sent a new enrollment card reflecting a new group number beginning with RH*. This process may take time, depending on when the Hospice Form is received by CMS and when their system is updated.

It is important that your staff and/or billing company understands the process required to bill the Fiscal  Intermediary for CMS for members of our Plan that are enrolled in hospice. Please communicate this information to your staff and/or billing company as appropriate..

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?

A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.


When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election


When a patient revokes hospice during an inpatient stay:

• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date