Currentblue cross blue shield - michiganPolicy N/A

5th Level Hospice Care

Defines coverage, provider requirements, billing and reimbursement rules for the 5th level inpatient hospice benefit offered to specified Medicare Plus Blue group members; affects participating hospice agencies and contracted skilled nursing/hospice facilities for applicable group plans.

Policy Summary

Payerblue cross blue shield - michigan

Policy5th Level Hospice Care

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionHospice agencies must bill directly for 5th level hospice services and contracted facilities must seek payment from the hospice agency rather than billing the plan or member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

210 daysURMBT lifetime maximum for 5th level hospice

45 daysUniversity of Michigan lifetime maximum

per diemReimbursement basis

0658Only reimbursable revenue code

appliesMember cost sharing

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Coverage Criteria and Limits

Coverage criteria and limits

Coverage is provided only to members of specified group plans and is subject to group-determined scope limits, reimbursement methodology, member cost sharing and eligibility requirements.

ALL of the following

Member must be enrolled in one of the covered group plans
- Member is enrolled in the UAW Retiree Medical Benefits Trust (URMBT) Medicare Plus Blue PPO group plan
- Member is enrolled in the University of Michigan Medicare Plus Blue PPO group plan
5th level hospice coverage is available only under the listed group plans; Original Medicare does not cover 5th level hospice and the groups determine scope of benefit and reimbursement methodologyN/A

ALL of the following

URMBT group plan members have a lifetime maximum of 210 days of 5th level hospice coverage210 days
University of Michigan group plan members have a lifetime maximum of 45 days of 5th level hospice coverage45 days

ALL of the following

Reimbursement is payable to a hospice agency participating with the local Blue Cross Blue Shield plan where services are provided
Reimbursement is on a per diem (per day) basis
Claims should be billed monthly at the per diem rate; when services cross calendar years, submit two separate claims (prior year remainder and new year services)
Only revenue code 0658 is reimbursable for URMBT and University of Michigan group plans; providers are liable for other services

Billing Codes and Frequency

Allowed revenue codeRevenueCovered

0658	Revenue code for 5th level hospice care (only reimbursable for URMBT and University of Michigan group plans)

Billing frequency and claim splitting

Billing frequencyClaims should be billed monthly at the per diem rate; for services that cross calendar years, split into two claims (one for prior year remainder and one for the new year)

Reimbursement basisPer diem (per day) basis; Medicare Advantage rate mirrors commercial rate

Billing unit and timingBill services monthly on a per diem basis using UB-04; hospice agency bills directly

Billing and Provider Responsibilities

Billing Rule

Billing and provider responsibilities for 5th level hospice care

Hospice agencies participating with the local Blue Cross Blue Shield plan must bill Medicare Plus Blue directly for 5th level hospice care; contracted skilled nursing or hospice facility providers must seek payment only from the hospice agency and must not bill the plan or the member. Services are reimbursable only during the member’s hospice election period; if the level of care changes, the physician’s order must be on file at the hospice agency for post‑payment audits. Bill on UB‑04 using the plan’s unique billing requirements, report revenue and diagnosis codes to the highest specificity, include your NPI, submit claims to the local Blue Cross plan, and bill monthly at the per‑diem rate (split claims when services cross calendar years). Only revenue code 0658 is reimbursable for the specified group plans; providers are liable for other services. Members are only responsible for cost‑sharing and cannot be balance billed.

Hospice agency bills Medicare Plus Blue directly for 5th level hospice care
Contracted skilled nursing/hospice facilities must seek payment from the hospice agency and must not bill the plan or member
Services reimbursable only during member’s hospice election period
Physician order must be on file if level of care changes (for audits)

Key Definitions

Terminally ill — definition

Definition (Medicare criteria)Terminally ill: medical prognosis of life expectancy six months or less if the illness runs its normal course

Election requirementAn individual (or authorized representative) must file an election statement with a particular hospice to receive care

Scope under Original MedicareOriginal Medicare covers hospice care in the home; inpatient hospice (respite and general inpatient) covered under specific conditions

Provider qualifications for 5th level hospice

Minimum participation requirementsCurrent Medicare certification as a hospice agency; state hospice licensure; participation with the local Blue Cross plan

Organizational memberships or structureMembership in NHPCO or Michigan Hospice and Palliative Care Organization, or a multi-disciplinary staff meeting specified roles