Hospice care
Applies to:
All plans. Medicare rules supercede the Medical Policy rules.
Definition
Care for patients with terminal conditions (if the natural course of the disease is followed, it leads to a life expectancy of six months or less), including home hospice care, inpatient and nursing home care, and respite care.
Medical policy
Hospice Care - 91520
Medicare Advantage hospice care billing
Under Medicare rules, the hospice benefit is covered for all Medicare beneficiaries under their Original Medicare benefits.
Jump down this page to see When a Medicare member revokes their hospice election
While a Medicare Advantage plan member is in hospice care
- Providers must bill Original Medicare for all hospice- and non-hospice-related services covered by Medicare Parts A and B.
- Priority Health Medicare Advantage plans cover non-hospice Part D drugs and supplemental benefits such as hearing aids, dental, etc.
| Service | Who pays | Cost share |
|---|---|---|
| Hospice-related service | Original Medicare | Original Medicare cost share |
| Non-hospice-related service | Original Medicare | Priority Health Medicare plan cost share. Provider must submit Medicare Summary Notice (MSN). Priority Health pays difference between Original Medicare and plan cost-share as applicable |
| One-time-only hospice evaluation/consultation | Priority Health | Priority Health Medicare plan cost share |
| Palliative care consultations for member in hospice | Original Medicare | Original Medicare cost share |
| Evaluation and management of pain visits, member not in hospice. Member must be home-bound to receive in the home. | Priority Health | Priority Health Medicare plan cost share |
References
- Hospice is covered by Original Medicare: Chapter 4, Section 10.4, Medicare Managed Care Manual
- Bill Original Medicare for all Part A and Part B services: Chapter 11, Section 30.4, Medicare Claims Processing Manual
When a member revokes their hospice election
The member remains on Original Medicare until the 1st of the following month.
- Original Medicare continues to pay for all claims for covered services during this period.
- All Original Medicare coverage rules apply, per WPS-Medicare Medicare Advantage Patient Electing Hospice Coverage.
- Priority Health starts paying claims for services covered by Medicare Parts A and B for dates of service on or after the 1st of the month following the month of the revocation.
If Medicare does not cover a service/procedure during this period
Priority Health does not pay for any benefit covered under Medicare Part A and B for dates of service on or between the date of the member's hospice revocation and the last day of the month of that revocation.
If you bill Priority Health for services offered during this period, we will return the claim as not covered and tell you to bill Medicare.