Hospice Care

Provider Type

Physicians
Participating Physician Groups (PPG)

Hospitals
Ancillary

Medicare hospice benefits are administered only through the original Medicare program. After the member has elected hospice, the member remains enrolled in the Health Net Medicare Advantage (MA).

For hospice services covered by Medicare Part A or B that are related to the terminal illness, the hospice provider bills Medicare and Medicare pays for hospice service and any Medicare Part A or B services.

For hospice services covered by Medicare Part A or B that are not related to terminal illness (except for emergency or urgently needed care), the provider bills Medicare for services and Medicare pays for the services covered by Medicare Part A and Part B.

Medications are never covered by both hospice and Health Net at the same time. Health Net covered non-hospice Part D medications are paid for by Health Net.

Health Net covered services, not covered by Medicare Part A or B that are offered as enhanced or supplemental benefits, whether they are related to terminal illness or not, are paid for by Health Net.

After the hospice election form is signed, all professional, ancillary and institutional claims for other Medicare-covered non-hospice services and services that are enhanced benefits under Health Net's MA plans must be submitted first to the Medicare administrator contractor. For more information on claims, refer to Claims Submission listed below. For additional information on cost-sharing and provider payment, refer to the table below.

The requirements for admission in the Medicare hospice program are:

The attending physician certifies that the member is terminally ill and is expected to live six months or less
The member chooses to receive only hospice care from a Medicare-certified hospice instead of therapeutic care under the MA plans for the terminal illness
The member has a caregiver available 24 hours a day
Care is provided by a Medicare-certified hospice program

Definition of Hospice Services

Hospice services are covered when the Health Net member has met hospice care requirements and the services are authorized by Health Net or a participating provider. Health Net or the participating physician group (PPG) is required to certify the member as terminally ill. The hospice and its employees must be licensed and certified by Medicare. For additional information, refer to Criteria for Hospice Appropriatenss (PDF).

Covered Hospice Services

The following services are covered under hospice when related directly to the terminal illness:

Professional services of a registered nurse, licensed practical nurse or licensed vocational nurse
Physical therapy, occupational therapy and speech therapy
Medical and surgical supplies and durable medical equipment
Prescribed medications
In-home laboratory services
Medical social service consultations
Inpatient hospice room, board and general nursing service
Inpatient respite care, which is short-term care provided to the member only when necessary to relieve the family or other persons caring for the member, when respite care is covered
Family counseling related to the member terminal condition
Dietitian services
Pastoral services
Bereavement services
Educational services
Home health aide services consisting primarily of a medical or therapeutic nature and furnished to a member who is receiving appropriate nursing or therapy services

To be covered by Medicare, hospice services must be consistent with the member's plan of care as prepared by the hospice.

Inpatient hospital or skilled nursing care may be required for palliation and management of terminal illness and related conditions. Inpatient care may also be furnished to provide respite for the member's family or other persons caring for the member at home if the member's plan provides coverage for respite care. Only qualified personnel may perform hospice services. The type of service, rather than the qualification of the person who provides it, determines the coverage category of the service.

Member Election of Hospice

Medicare beneficiaries enrolled in managed care plans may elect hospice benefits.

A terminally ill member may have two 90-day election periods followed by an unlimited number of 60-day periods. The member may revoke the election at any time in writing by filing a document with the hospice; the member forfeits hospice coverage for any remaining days in that election period. Upon revoking the election of Medicare coverage of hospice care for a particular election period, the member resumes Medicare coverage of the benefits waived when hospice care was elected. Claims for services provided after hospice care has been revoked but before the beginning of the month after the month hospice was revoked (and full capitation payments resume) must be submitted to the appropriate Medicare intermediary or carrier for payment.

A member who elects hospice care, but chooses not to disenroll from the plan, is entitled to continue to receive services through the MA plan. This is specific to any benefits other than those that are the hospice's responsibility. Through the Original Medicare program and subject to the standard rules of payment, CMS pays the hospice program for hospice care furnished to the member and the MA organization, providers and suppliers for other Medicare-covered services furnished to the member.

The table below summarizes the cost-sharing and provider payments for services furnished to an MA plan member who elects hospice.

Cost-Sharing and Provider Payment

Type of Service	Member Coverage Choice	Member Cost-Sharing	Payment to Providers
Hospice program	Hospice program	Original Medicare cost-sharing	Original Medicare
Non-hospice, Part A and B	MA plan or Original Medicare	MA plan cost-sharing, if member follows MA plan rules Original Medicare cost-sharing, if member does not follow MA plan rules	Original Medicare
Non-hospice, Part D	MA plan (if applicable)	MA plan cost-sharing	Health Net
Supplemental	MA plan	MA plan cost-sharing	Health Net

Hospice Consideration Request Letter

To further assist providers in proper utilization of hospice care, Health Net has developed a Hospice Consideration Request (PDF) letter template. The template may be used to notify a PCP or attending physician of a member's need for hospice care.

Services Unrelated to the Terminal Condition

Coverage under Original Medicare for conditions completely unrelated to the terminal condition for which hospice was elected remains available to the member if they are eligible for such care. The member is also eligible for enhanced benefits offered by Health Net's MA plans.

The participating provider must inform the hospice and the member that, regardless of the forms signed upon election and admission to a hospice program, the member is still required to have all non-hospice-related care directed, arranged and authorized, if required, by the member's PCP or the PPG, with the exception of Violet plan members who can select either a participating or non-participating provider, depending on the desired level of coverage.

If a member electing hospice needs prescription medications for conditions not related to hospice care, these costs are the MA organization's responsibility to the extent the medications are covered under Part D or the MA organization's plan.

The participating provider must contact the Health Net Utilization Management Department to report each instance the provider executes a Certificate of Terminal Illness for a member.

To receive payment for Medicare-covered hospice services, a hospice provider must obtain a written certification of the member's terminal illness from the member's primary care physician (PCP) or attending physician who has the most significant role in determining and delivering the member's medical care for the first 90-day period of hospice coverage. The certification must be on file in the hospice patient's record prior to the provider submitting a claim for hospice-related services. Certifications may be completed up to two weeks before the member elects hospice care. For subsequent hospice election periods, the hospice must obtain, no later than two calendar days after the first day of each election period, a written certification from the medical director of the hospice or the physician member of the hospice's interdisciplinary group. The first election period is for a 90-day period. An individual may elect to receive Medicare coverage for an unlimited number of election periods of hospice care. The periods consist of two 90-day periods followed by an unlimited number of 60-day periods.

The written certification must include:

Statement that the member's medical prognosis is life expectancy of six months or less according to the terminal illness normal course
Specific clinical findings and other documentation supporting the life expectancy of six months or less
Signatures of the PCP or other participating provider who is the attending physician and a physician affiliated with the hospice

Definition of Terminal Illness

A member is considered to be terminally ill if the medical prognosis is that the individual's life expectancy is six months or less if the illness runs its normal course.

Election of Terminal Illness

Each hospice designs its own election statement, which should include the following elements:

Hospice program
Member or representative's acknowledgment of full understanding of hospice care
Hospice effective date
Signature of member or representative
Language explaining that the member may revoke hospice services at any time
Member or representative's acknowledgment of full understanding that certain Medicare services are waived by the election of hospice

The following information applies only to participating physician groups (PPGs) and Ancillary providers.

Hospice physicians or hospice nurse practitioners (NPs) must have a face-to-face encounter with every hospice patient to determine continued hospice eligibility. To satisfy this requirement, the following criteria must be met:

The face-to-face encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.
The hospice physician or NP who conducts the face-to-face encounter must attest in writing to it. The attestation must be on a separate and distinct section of, or addendum to, the recertification form, be clearly titled and include the rendering physician's or NP's signature and date of face-to-face encounter. When an NP conducts the face-to-face encounter, the attestation must state the clinical findings were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less, if the illness runs its normal course.

In cases where a hospice newly admits a patient in the third or later benefit period, exceptional circumstances may prevent a face-to-face encounter prior to the start of the benefit period (as described in criteria 1). For example, if the patient is an emergency admission on a weekend, it may be impossible for a hospice physician or NP to see the patient until the following Monday, or the hospice may be unaware that the member is in the third benefit period. In such documented cases, a face-to-face encounter within two days after admission is considered timely. If the patient dies within two days of admission without a face-to-face encounter, a face-to-face encounter can be deemed as completed.

The hospice must retain the certification statements and have them available for Health Net's audit purposes.

Medicare's Payments to Hospice Programs

Hospice is covered by original Medicare regardless of whether a hospice patient has fee-for-service (FFS) coverage or managed care coverage. Original Medicare pays physicians, providers and suppliers for other Medicare-covered services furnished to members who have elected hospice. Other non-hospice Part D drug benefits refer to non-hospice, Part A or Part B services that are not related to the terminal illness. Once a member has been approved by the Centers for Medicare and Medicaid Services (CMS) as having elected hospice benefits, all capitation stops. However, members who have elected hospice may revoke hospice election at any time. Full monthly capitation payments resume on the first day of the month after the member has revoked hospice election.

For members who have elected hospice services, Health Net's Medicare Advantage (MA) are responsible for making available all other non-hospice Part D drug benefits and any non-hospice services that are not Medicare-covered, but that are offered as supplemental or enhanced benefits under the MA plans.

The Medicare Administrative Contractors (MACs) denies claims for any services covered under Part A or Part B furnished to a member who has elected hospice that is submitted without the GV or GW modifier. If claims are denied from the Medicare MAC due to missing GV or GW modifiers, providers should resubmit claims to the Medicare MAC with applicable. For ease of administration and timely reimbursement, participating providers should submit all claims for services rendered to a member who has elected hospice to the responsible Medicare MAC or carrier as described below. Providers must also submit claims for non-Medicare covered services, which are offered as enhanced benefits by the Health Net plan to the Medicare MAC or carrier. Refer to the member's Evidence of Coverage (EOC) for descriptions of enhanced benefits.

When a participating provider renders other Medicare-covered services unrelated to the terminal illness or services that are covered by the MA plans as enhanced benefits, the provider must use modifier GW (for services unrelated to the terminal illness). Once the participating provider receives Medicare's Medicare Summary Notice (MSN), which describes remaining, non-Medicare covered charges for services, the participating provider submits a claim with the MSN to Health Net for payment of the balance according to terms of the Provider Participation Agreement (PPA). Refer to chart below for the step-by-step process of submitting hospice-member claims.

Type of Provider	Claims for Professional Services Related to Hospice Care	Claims from Facilities for Services Related to Hospice Care	Claims for Services Not Related to Hospice Care	Claims for Non-Medicare-Covered, Enhanced Benefits Offered as Part of Health Net's Benefits
Hospital	N/A	Submit claims to MAC	Submit claims to MAC for primary processing, and then to Health Net for secondary processing	Submit claims to MAC for primary processing, and then to Health Net for secondary processing
Other Ancillary Providers	Submit claims to MAC	Submit claims to MAC	Submit claims to MAC for primary processing, and then to Health Net for secondary processing	Submit claims to MAC for primary processing, and then to Health Net for secondary processing
PPG/Physician	Submit claims to MAC	N/A	Submit claims to MAC for primary processing, and then to Health Net for secondary processing	Submit claims to MAC for primary processing, and then to Health Net for secondary processing
Certified Hospice Providers	N/A	Submit claims to regional home health intermediaries (RHHIs)	N/A	N/A

If a member who has elected hospice needs prescription medication for conditions not related to hospice care, these costs are the MA organization's responsibility to the extent the medications are covered under Part D or under the MA organization's plan formulary.

Federal regulations require that the RHHIs are responsible for paying for hospice services and for claims the RHHI may pay as a regular servicing MAC for managed care members who elect hospice. MAC claims for Medicare-covered services not related to the terminal illness are the responsibility of another MAC.

Revocation of Hospice Election

Members who have elected hospice may revoke hospice election at any time. When this occurs, general coverage under Medicare is reinstated for the member. Full monthly capitation payments resume on the first day of the month after the member has revoked hospice election. Claims for services provided after hospice has been revoked, but before the beginning of the month after the month hospice was revoked (and full capitation payments resume), must be submitted to the appropriate Medicare intermediary or carrier for payment.