VBID Model Hospice Benefit Component Quick Links:
How do I bill for hospice services under this model?
Under the Hospice Benefit Component of the Value-Based Insurance Design (VBID) Model, how you will bill depends on whether you have a contract with the participating Medicare Advantage (MA) plan. If you have a contract, follow the requirements for billing and payment agreed to in the contract between you and the participating plan. If you do not have a contract (otherwise known as “out-of-network”), then you can bill the participating plan in the same way that you bill your Medicare Administrative Contractor (MAC) for hospice care. Regardless of your contractual status, you must send all claims and notices for enrollees in a participating plan to your MAC.
How do you check a patient’s enrollment in a Hospice Benefit Component-participating plan?
See the instructions on this page.
What billing requirements do Medicare Advantage plans have?
Billing requirements under the Model depend on whether you have a contract with the participating plan. If you have a contract, follow the requirements for billing and payment agreed to in the contract between you and the participating plan. If you do not have a contract (otherwise known as “out-of-network”), then the billing requirements for the participating plan will be the same as the requirements for your MAC for hospice care. Find more information on billing and payment for hospice services in the Medicare Claims Processing Manual, Chapter 11. Participating plans may have similar requirements for timely submission of notices, and the length of time that you have to submit claims. CMS encourages hospice programs to reach out to the MA plans who are participating in the Hospice Benefit Component of the VBID Model. Find contact information for these participating MA plans here.
Whom do I contact if I have questions about eligibility and billing?
If you have questions about eligibility and billing, contact the participating MA plan to confirm an enrollee’s coverage with that plan. Find contact information for these plans here.
Is participation in the Model optional for hospice providers?
If you provide services to an enrollee who receives their Medicare coverage through a participating plan, your Medicare Administrative Contractor will not provide payment for any services that you provide—you must bill the participating MA plan to receive payment for these services.
However, you get to choose if you want to contract with the participating plan. If you remain an out-of-network provider, you should contact the participating MA plan if you begin providing hospice care to a patient enrolled in their plan, and you can bill the participating plan in the same way that you would bill your Medicare Administrative Contractor for hospice care.
If a national parent organization is participating, are all of its plans nationally participating?
Just because an MA plan that is part of a large national MAO participates in the Hospice Benefit Component of the VBID Model does not mean that all of the MA plans for that MAO are participating. Visit this page to confirm if a particular plan is participating.
If there is no participating plan in my service area, can I still be impacted by the Hospice Benefit Component of the VBID Model?
If you are not in the service area of a participating plan, you will likely have little to no impact from the Hospice Benefit Component of the VBID Model for Calendar Year (CY) 2022 in comparison to hospice providers providing hospice care in the service areas of participating plans. You do not need to reach out to contract with a participating plan if you do not provide care in that plan’s service area.
In the event that a hospice-eligible eligible enrollee travels outside their service area (which could even mean outside his/her home state) and elects hospice care while visiting, the plan participating in the Hospice Benefit Component will cover Part A hospice care received at a rate equal to the Original Medicare Fee-For-Service (FFS) payment for hospice services. It is important to note that enrollees of participating plans can choose any Medicare-certified hospice provider they want (including those outside their plan’s service area).
You should plan to check your patients’ Medicare enrollment and coverage, and identify whether they are enrolled in a participating plan, prior to providing services or billing your Medicare Administrative Contractor on or after the start of the calendar year. If you provide hospice services to a patient enrolled in a participating plan, you should send all notices and claims to both the participating plan (for payment) and the Medicare Contractor (for informational and operational processing and monitoring). You can use the same Original Medicare forms to send to both.
What is a contracted provider? How do I know if I am contracted, or in-network?
Under the Model, a contracted provider is a provider that enters into a written agreement with a participating plan to furnish Original Medicare services to its plan’s enrollees. The contract between the provider and the participating plan may specify payment rates, services the provider will offer, and rules around how to bill or interact with the plan. Contracted providers are also known as in-network providers. If the hospice provider has not signed a contract with a participating plan, then that provider is out-of-network for that plan until a network contract has been established.
Is there a prior authorization process for hospice care?
Under the Model, participating MA plans cannot require prior authorization or utilization management review on hospice care except with respect to prepayment or post-payment review. If Medicare Part A would normally cover the hospice care, a participating MA plan cannot refuse to provide coverage, and may not review care to determine if it is covered.
In situations where the participating MA plan notices a pattern that risks patient harm or is a program integrity risk, the plan may conduct prepayment or post-payment review. Prepayment or post-payment review is not the same as prior authorization. Participating MA plans should conduct this review across a number of claims and not at the individual patient level.
What happens if an enrollee changes plans during a hospice election? Is a new Notice of Election needed?
If an enrollee changes plans during a hospice election, coverage for that enrollee’s care depends on his/her current enrollment. You only need a new Notice of Election when the enrollee revokes and then re-elects hospice care. Read more details in the CY2021 Hospice Benefit Component Technical and Operational Guidance Document, section 3. Please note this technical and operational guidance is generally applicable for CY 2022; please reach out to the VBID Model at VBID@cms.hhs.gov with any questions.