Hospice Services
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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 metadata shows Original MPC Approval 09/17/2018, Last Review 11/12/2025, Effective Date 02/01/2026.
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.
Applicability: coverage and any prior authorization requirements depend on the member's contract and line of business; contract provisions supersede this policy. Hospice services (home and inpatient/facility) must be preauthorized per CareFirst provider guidance.
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
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.
Check Member Contract for Benefits
Verify the member's contract for specific hospice benefits, restrictions, and exclusions; contract provisions supersede this clinical policy.
Use Hospice-Facility Reimbursement Policy
Refer to Reimbursement Policy PP CO 900.02 Hospice-Facility for proper billing of hospice services.
Coding / Billing Reference
| No codes listed |
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
Original MPC Approval recorded on 09/17/2018. No clinical policy statement changes noted.
Last Review Date recorded on 11/12/2025. No clinical policy statement changes noted.
Effective Date set to 02/01/2026. No clinical policy statement changes noted.
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