CurrentCareFirstPolicy 2.01.076

Hospice Services

Defines CareFirst coverage stance for hospice and palliative care services for terminally ill members including levels of care (routine home, inpatient, continuous home care, respite), benefits, preauthorization requirement, and applicability relative to member contracts and clinical trials.

Policy Summary

PayerCareFirst

PolicyHospice Services

Policy CodePolicy 2.01.076

Change TypeAdministrative update

Effective Date02/01/2026

Next Review Date

Key ActionPreauthorize hospice services by submitting requests online at www.provider.carefirst.com or call 1-866-773-2884 and verify member contract benefits.

POLICY UPDATE CHANGES

Policy metadata shows Original MPC Approval 09/17/2018, Last Review 11/12/2025, Effective Date 02/01/2026.

4Levels of Hospice Care Defined

9Examples of Benefits Listed

Coverage Summary

CareFirst considers hospice and palliative care services covered with criteria for members who are terminally ill as defined by the member's contract. Members may continue receiving palliative care services and medically necessary services are determined at CareFirst's discretion.

CareFirst recognizes the following levels of hospice care: Routine Home Care, Inpatient Care, Continuous Home Care (CHC), and Respite Care.

Medical Necessity Criteria

Medically Necessary Hospice and Palliative Care

Hospice and palliative care services are considered medically necessary for the terminally ill member as defined by the member's contract. Members may continue with palliative care services. Medically necessary services are determined at CareFirst's discretion.

Terminal Illness Requirement: Member is terminally ill as defined by the member's contract
Scope of Services: Services provided are palliative and supportive to meet the physical, psychological, spiritual, and social needs of the terminally ill member and family
Includes palliative care intended to relieve pain and distressing symptoms, influence course of illness, and enhance quality of life
Setting and Levels of Care: Care is provided in an appropriate setting and at an appropriate level of hospice care
Appropriate settings include home, hospice facility, or inpatient care; levels of hospice care include Routine Home Care, Inpatient Care, Continuous Home Care (CHC), and Respite Care
Medical Necessity Determination: Services, devices, and drugs are medically necessary and consistent with CareFirst discretion
CareFirst determines medical necessity and may cover other medically necessary services at its discretion
Preauthorization Requirement: Preauthorization/prior authorization obtained where required by member contract and CareFirst policies
Providers should submit preauthorization requests online at www.provider.carefirst.com or call 1-866-773-2884; use the PAL Tool for prior authorization requirements

Provider Actions / Prior Authorization

Prior Authorization

Preauthorization Required for Hospice Services

Hospice services (home and inpatient/facility) must be preauthorized. Providers should submit preauthorization requests online at www.provider.carefirst.com or call 1-866-773-2884. For prior authorization requirements use the PAL Tool at https://provider.carefirst.com/prv/priorauth.

Documentation Required

Check Member Contract for Benefits

Verify the member's contract for specific hospice benefits, restrictions, and exclusions; contract provisions supersede this clinical policy.

Billing Rule

Use Hospice-Facility Reimbursement Policy

Refer to Reimbursement Policy PP CO 900.02 Hospice-Facility for proper billing of hospice services.

Background and Definitions

Hospice care is described as a coordinated, interdisciplinary program that meets the physical, psychological, spiritual, and social needs of terminally ill individuals and their families by providing palliative and supportive medical, nursing, and other health services through home, hospice facility, or inpatient care during illness and bereavement.

CareFirst recognizes these levels of hospice care: Routine Home Care, Inpatient Care, Continuous Home Care (CHC), and Respite Care.

Term	Definition
Hospice Care
A coordinated, interdisciplinary program providing palliative and supportive medical, nursing, and other health services through home, hospice facility or inpatient care during illness and bereavement for terminally ill individuals.
Levels of Hospice Care
Routine Home Care; Inpatient Care; Continuous Home Care (CHC); Respite Care.

Revision History

09/17/2018Administrative Update

Original MPC Approval recorded on 09/17/2018. No clinical policy statement changes noted.

11/12/2025Administrative Update

Last Review Date recorded on 11/12/2025. No clinical policy statement changes noted.

02/01/2026Administrative UpdateLatest

Effective Date set to 02/01/2026. No clinical policy statement changes noted.