Determining when to bill Original Medicare when an enrollee has elected hospice can be confusing. Good news! HealthTeam Advantage is here to offer clarity and understanding to make the decision easier. Per the Medicare Benefit Policy Manual, Chapter 9 Section 20.4, a managed care enrollee (Medicare Advantage member) may elect the hospice benefit with Original Medicare. After the hospice election, Medicare (Original) pays the hospice for the following:
Once the enrollee is under hospice election, a managed care patient (a.k.a. Medicare Advantage member) may choose to use a provider outside of their managed care organization for care unrelated to the terminal illness or related conditions, or as the attending physician. For more information see Pub. 100-04, Medicare Claims Processing Manual, chapter 11, section 40 for requirements for physician billing.
Once a managed care enrollee has elected hospice, all of their Medicare benefits revert to fee-for-service and should be billed to Original Medicare. The enrollee can remain on the managed care plan (such as HTA) for any additional benefits such as dental or vision coverage. During the election, the Medicare hospice benefit through fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness from the effective date of election to the date of discharge or revocation.
Upon discharge or revocation, fee-for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive. At the start of the month following revocation or discharge, all billing and coverage revert to the managed care plan. (see Pub 100-04, Medicare Claims Processing Manual, chapter 11, §30.4). Deciding whether to file the managed care plan or original Medicare is simple. If the enrollee has elected hospice, ALL claims must be filed to original Medicare. Still, have questions? No problem! Contact our Provider Concierge by phone at 855-218-3334 or by email providerconcierge@healthteamadvantage.com.