CMS Pub. 100-16, ch. 8, § 70.3

Enrollees Electing Hospice in CCP and PFFS Plans. Effective CY 2006 for CCP and

PFFS plans, during the time the hospice election is in effect, CMS pays the MA

organization the portion of the monthly payment attributable to the rebate, minus the

amounts (if any) of rebate allocated to reduce the Part B premium and the Part D basic

premium, plus the amount of the subsidy CMS pays the MA organization for a plan

enrollee related to basic prescription drug coverage (if the enrollee is in an MA-PD plan).

• The amount by which the plan reduces enrollees’ Part B premium is foregone

revenue that remains in the Treasury, allowing CMS and SSA to decrease the

enrollee’s Part B premium by this amount. The amount by which the plan reduces

the basic Part D premium is reflected in the Part D payment to the plan.

• Regarding the Part D benefit, if an MA-PD plan enrollee electing hospice needs

prescription drugs for conditions not related to hospice care, these costs are the MA

organization’s responsibility (to the extent that the drugs are covered under Part D

or under the plan). CMS pays MA-PD organizations the Part D subsidy for all

enrollees, including those electing hospice.

Enrollees Electing Hospice in an MSA Plan. Beneficiaries who have elected hospice are

not allowed to enroll in an MSA plan. Members may elect hospice and remain in the MSA

plan. CMS’ monthly capitation payment will be zero, because there is no portion of the

monthly payment from CMS for the high deductible health plan that is attributable to

supplemental benefits. Moreover, MSA plans cannot offer Part D coverage.

70.3.1 - CMS’ Payments to Hospice Programs

(Rev. 118; Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012 (for ASC X12 5010); Implementation: ICD-10: Upon Implementation of ICD-10,

ASC X12: January 1, 2012 (for ASC X12 5010))

The hospice is paid through the original Medicare program, subject to the usual rules of

payment, for hospice care furnished to the Medicare enrollee. See the Medicare Claims

Processing Manual, Chapter 11 on Hospice on the CMS Web site at

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html

Section 40.2.2(B) of Chapter 11 notes that Medicare hospices will bill the A/B MAC (HH) for

Medicare beneficiaries who have coverage through managed care just as they do for

beneficiaries with fee-for-service coverage.

Original Medicare pays physicians, providers and suppliers for other Medicare-covered

services furnished to enrollees who have elected hospice. “Other services” refer to non-hospice A/B services that are not related to the terminal illness.

For other Part B services furnished to enrollees who have elected hospice, original

Medicare will also pay the MA organization to the extent a claim has been reassigned to

the MA organization. Under §1861(u) of the Act, Part A claims from “providers of

services” cannot be reassigned.

The MA organization is responsible for making available to its members who have elected

hospice all Medicare-covered non-hospice services and also any non-hospice services that

are not Medicare-covered, but that are offered as supplemental benefits under the plan. For

example, services provided by an attending physician to an MA enrollee who has elected

hospice are considered non-hospice services, if the physician is not employed or contracted

by the enrollee’s hospice program, and may be reimbursed by original Medicare.

Since an MA organization cannot bill an A/B MAC (A), nor can an A/B MAC (A) make

payments to MA organizations, below are examples of how MA organizations may choose

to handle billing for non-hospice (“other”) services by contracted providers:

• The MA organization can authorize the provider (e.g., hospital or physician) or

supplier to bill the MAC directly. (In such a situation, the MA organization might

also choose to incorporate rate adjustments in contracts to account for the provision

of non-hospice services by providers and suppliers that bill original Medicare

directly.)

• In the case of physician and supplier services, the MA organization may direct them

to submit claims for non-hospice services to the MA organization. The MA

organization would bill the A/B MAC (B) and make payments to the

physicians/suppliers.

Under original Medicare (and thus under the MA program during hospice elections), the

beneficiary is responsible for certain cost sharing for hospice services:

• Co-pay for Part B drugs and biologicals: No more than $5 for each drug and other

similar products for pain relief and symptom control.

• Co-pay for a respite care day: 5 percent of the payment that Medicare makes for a

respite care day, not to exceed the hospital inpatient deductible.