Medi-Cal Provider Manual, Part 2, Hospice Care: General Billing Instructions, Medicare/Medi-Cal Recipients

For Medicare/Medi-Cal-eligible recipients, Medicare will be the first payer of hospice care.

Medi-Cal covers both coinsurance for drugs and respite care on behalf of Medicare/Medi-Cal

recipients, and room and board allowance for recipients residing in Nursing Facility (NF)

Level A or B.

If the Medicare-eligible recipient has any other health insurance coverage, a copy of the

Explanation of Benefits (EOB), Remittance Advice (RA) or denial letter must accompany

each Medi-Cal claim for services. More information is available in the Other Health

Coverage (OHC) Guidelines for Billing in the Part 1 manual.

Note: Providers billing hospice care revenue codes 0552, 0650, 0652, 0655, 0656, 0657 or

0659 for Medi-Cal recipients who are entitled to Medicare, but not eligible for Part A

coverage on the date of service, may bill Medi-Cal directly. Medicare denial

documentation is not required with these claims.

Revenue code 0657 is not reimbursable when physician services are not related to the

treatment of the terminal illness. Such treatment must be billed to Medicare as a Part B

covered service, as appropriate.

Medicare/Medi-Cal Billing for Coinsurance

When hard copy billing Medi-Cal for coinsurance amounts, hospices must send the

California MMIS Fiscal Intermediary a copy of the Medicare claim with an attached copy of

the Medicare RA. This shows that the Medicare payment was made for hospice care during

the period covered. Pursuant to state regulation, coinsurance may not be billed for recipients

eligible for Medicare or Medi-Cal unless the hospice also bills and collects coinsurance from

Medicare-only recipients.

Medicare/Medi-Cal Billing for Room and Board

When billing Medi-Cal for room and board charges, hospices must send the FI a copy of the

Medicare claim covering the same dates of service or must enter in the Remarks field

(Box 80), or attachment to the claim, the date that Medicare was billed, the concurrent dates

of hospice care services and the hospice care codes billed.