CMS Pub. 100-16, ch. 4, § 10.4

As defined in 42 CFR §422.320, MA plans must inform each enrollee eligible for hospice

care about its availability. This is true whether a Medicare hospice program is located

within the plan's service area or if it is common practice to refer patients to hospice

programs outside the plan’s service area.

An MA enrollee who elects hospice care, but chooses not to disenroll from the plan, is

entitled to continue to receive through the plan any MA benefits other than those that are

the responsibility of the hospice. Under such circumstances, the MA plan is paid a

reduced capitation rate for that enrollee by CMS and the MA plan is responsible for

continued coverage of supplemental benefits. CMS pays: (a) the hospice program for

hospice care furnished to the enrollee and (b) the MA plan, providers, and suppliers for

other Medicare-covered services furnished to the enrollee through the original Medicare

program, subject to the usual rules of payment.

Hospice coverage is effective immediately on the date of election; the reduced rate paid

to the MA plan begins the next month (42 CFR §422.320).

Table I below summarizes the cost-sharing and provider payments for services furnished

to an MA plan enrollee who elects hospice.

Table I: Payments for Services Furnished to an Enrollee who has Elected Hospice

Type of Services Enrollee Coverage

Choice Enrollee Cost-sharing Payments to

Providers

Hospice program Hospice program Original Medicare cost-sharing

Original

Medicare

Non-hospice care1, Parts

A & B

MA plan or original

Medicare

MA plan cost-sharing,

if enrollee follows MA

plan rules3

Original

Medicare2

Original Medicare cost-sharing, if enrollee

does not follow MA

plan rules3

Original

Medicare

Non-hospice care1, Part

D

MA plan (if

applicable) MA plan cost-sharing MAO

Supplemental MA plan MA plan cost-sharing MAO

Notes:

1) The term ‘hospice care’ refers to original Medicare items and services related to the

terminal illness for which the enrollee entered the hospice. The term ‘non-hospice

care’ refers either to services not covered by original Medicare or to services not

related to the terminal condition for which the enrollee entered the hospice.

2) If the enrollee chooses original Medicare for coverage of covered, non-hospice-care,

original Medicare services and also follows MA plan requirements, then, the

enrollee pays plan cost-sharing and original Medicare pays the provider. The MA

plan must pay the provider the difference between original Medicare cost-sharing

and plan cost-sharing, if applicable.

3) An HMO enrollee who chooses to receive services out of network has not followed

plan rules and therefore is responsible to pay FFS cost-sharing; a PPO enrollee who

receives services out of network has followed plan rules and is only responsible for

plan cost-sharing. The enrollee need not communicate to the plan in advance his/her

choice of where services are obtained.

Please see the following resources for additional information:

• The Social Security Act, section 1853(h)(2)(B); and

• The Medicare Claims Processing Manual, chapter 11 - Processing Hospice Claims,

section 30.4