VBID Model Hospice Benefit Component Coverage

When a patient enrolled in a Medicare Advantage (MA) plan participating in the Hospice Benefit Component of the VBID Model (or the “Model”) elects hospice, the plan generally covers all of their Medicare benefits, including hospice care. Each participating MA plan must include all the services covered by the Part A hospice benefit under Fee-For-Service Medicare. “Unbundling” of the hospice benefit is NOT allowed.

Like Fee-for-Service Medicare, hospice coverage starts from the effective date of election until the date of discharge or when the patient chooses to revoke hospice benefits. The participating plan offers coverage and payment for in-network hospice providers, who sign a contract with the participating plan to provide services to their plan enrollees. All participating plans must cover and pay for hospice care provided by an out-of-network hospice provider in 2021, 2022, 2023 and/or 2024 (depending on years of plan participation in the Model Component) at least at Original Medicare rates. An out-of-network hospice provider is responsible for submitting all notices and claims to both its Medicare Administrative Contractor (MAC) and the MA plan. An in-network provider must submit all notices and claims to its MAC and must follow billing and claims processing requirements in alignment with its contractual agreements with the participating plan.

Prior authorization or other utilization management requirements are not allowed on hospice care under the Model. Prepayment or post-payment review is allowed for hospice care and care unrelated to the terminal illness and related conditions under the Model.

MA plans participating in the Model may also offer other services (like palliative care outside the hospice benefit, or hospice supplemental benefits like meals, transportation, or additional in-home caregiver support) that are available to enrollees under certain circumstances. For more information on these services, contact the participating Medicare Advantage Organization (MAO) with MAO contact information listed here.