Currentblue cross blue shield - michiganPolicy N/A

Hospice Care (Medicare Advantage enhanced benefit)

Governs coverage and reimbursement rules for hospice care for Medicare Advantage (Medicare Plus Blue / BCN Advantage) members, including member cost sharing reimbursement and billing responsibilities; affects providers and members enrolled in applicable BCN Advantage plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyHospice Care (Medicare Advantage enhanced benefit)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionHospices should bill the Regional Home Health Intermediaries (Medicare contractors) for BCN Advantage members who elect hospice.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5maximum consecutive days covered for inpatient respite care

6 monthslife expectancy threshold to qualify as terminally ill

5%coinsurance amount members must verify for reimbursement

Medicare Part Aprimary program that provides hospice benefit

Hospice Coverage Criteria and Reimbursement Rules

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Hospice coverage criteria and billing rules

Coverage and reimbursement rules applicable when a BCN Advantage member elects hospice:

When a Medicare beneficiary entitled to Part A elects hospice for a terminal illness, hospice benefits are provided under Medicare; only care provided by a Medicare-certified hospice is covered. An individual is considered terminally ill if life expectancy is six months or less if the illness runs its normal course.

Medicare fee-for-service contractors retain payment responsibility for BCN Advantage members who elect hospice; hospices should bill the Regional Home Health Intermediaries (Medicare contractors). Original Medicare (not BCN Advantage) processes non-hospice Part A and Part B services provided to members who have elected hospice.

BCN Advantage may offer an enhanced benefit reimbursing the member's coinsurance for members of select BCN Advantage plans that include this benefit. Members or their authorized representatives must submit a reimbursement request with member name, BCN Advantage contract and group number, member address, and a legible copy of the Medicare Summary Notice and/or receipts verifying the coinsurance (5%) to the specified BCN address.

Providers should collect the applicable Medicare Plus Blue cost sharing from the member at the time of service when possible and may only collect the appropriate Medicare Plus Blue cost sharing amounts. Providers may not require members to sign an Advance Beneficiary Notice of Noncoverage to accept financial responsibility for noncovered items; if coverage is uncertain, providers must obtain a coverage determination from Medicare Plus Blue before providing the item. If a provider issues a noncovered item without a prior coverage determination, the member must be held harmless for all charges except any applicable cost share.

Payment for inpatient respite care may not be provided for more than five consecutive days at a time.

Billing, Claim Routing, and Provider Responsibilities

Billing Rule

Bill Medicare contractors (Regional Home Health Intermediaries) for BCN Advantage members who elect hospice

Medicare fee-for-service contractors retain payment responsibility for BCN Advantage members who elect hospice; hospices must bill the Regional Home Health Intermediaries (Medicare contractors) for these members and Original Medicare, not BCN Advantage, processes non‑hospice Part A and B services for them.

Do not bill BCN Advantage for hospice claims — Medicare fee‑for‑service contractors (e.g., Regional Home Health Intermediaries) are responsible for payment.
Non‑hospice Part A and B services related to BCN Advantage members who elect hospice are processed by Original Medicare rather than BCN Advantage.

Key Definitions

Terminally ill

DefinitionTerminally ill — an individual whose medical prognosis indicates a life expectancy of six months or less if the illness runs its normal course.

Eligibility triggerMedicare beneficiaries entitled to Part A with a life expectancy of six months or less may elect hospice benefits in lieu of standard Medicare coverage for treatment and management of the terminal condition.

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

Provider certificationOnly care provided by a Medicare-certified hospice is covered under the hospice benefit provision.

Inpatient respite care

DefinitionInpatient respite care — short-term inpatient care furnished to provide a reprieve for the individual's family or other persons caring for the individual at home.

PurposeProvides temporary relief for caregivers rather than ongoing inpatient treatment for the terminal illness.

Payment limitPayment for hospice respite care may not be provided for more than five consecutive days at a time.

Medicare contextRespite is one of two Medicare-covered inpatient levels (respite and general inpatient care) under the hospice benefit.