HOPE Guidance Manual v1.02, Item A1400

Timepoint(s) Item Completed

Admission (ADM)

HOPE Update Visit 1 (HUV1)

HOPE Update Visit 2 (HUV2)

Item-Specific Instructions

• Check the box(es) that best correspond(s) to the patient’s current existing payment sources. Check all

that apply.

o This item is intended to identify all current, existing payer sources that the patient has, regardless of

whether or not the payer is expected or likely to provide reimbursement for any services, supplies,

medications, etc., that the patient may receive during the hospice stay.

o Pending payer sources should not be included (i.e., do not report payment source(s) which have

been applied for but not yet received).

o Payer sources can be based on patient/caregiver report.

o It is recommended that providers make efforts to validate existing payer sources (e.g., ask patients to

present their Medicare card).

• Code A, Medicare (traditional fee-for-service), if the patient has traditional fee-for-service

Medicare Parts A, B and/or D.

• Code B, Medicare (managed care/Part C/Medicare Advantage), if the patient has Medicare

HMO/managed care, another Medicare Advantage Plan, or Medicare Part C.

o If the patient had Medicare Advantage prior to enrolling in hospice, select response option B even

though Medicare Advantage may not reimburse the hospice directly for any services.

o If the patient had Part C/Medicare Advantage prior to enrolling in hospice, select the response

options for BOTH part C and traditional fee-for-service Medicare or Medicaid, as applicable.

• Code C, Medicaid (traditional fee-for-service), if the patient has traditional fee-for-service

Medicaid.

• Code D, Medicaid (managed care), if the patient has Medicaid managed care.

• Code G, Other government (e.g., TRICARE, VA, etc.), if the patient has a government plan

besides Medicare and/or Medicaid. This would include other government insurance such as TRICARE,

VA, etc.

• Code H, Private Insurance/Medigap, if the patient has any private insurance available.

o Include commercial plans irrespective of how they were purchased (i.e., regardless of whether

provided through an employer, purchased individually by the patient, or through a health insurance

exchange, etc.).

o Use this for prescription drug coverage from a private insurer in addition to/other than Medicare Part

D coverage.

• Code I, Private Managed Care, if the patient has any private insurance available that is a managed

care plan.

o Include commercial or those privately purchased (e.g., commercial HMO or PPO plans) irrespective

of how they were purchased (i.e., regardless of whether provided through an employer, purchased

individually by the patient, or through a health insurance exchange, etc.).

• Code J, Self-pay, if the patient has any amount of personal funds available to contribute to healthcare

expenses (services, supplies, medications, etc.) during the hospice stay.

o Based on this definition of self-pay, for certain providers, a large majority of patients may be

identified as self-pay; this is acceptable.

o Self-Pay should be chosen even if the patient is not actively paying for anything but could pay for

something or has the funds if needed.

o The intent of the Self-Pay response option is not to assess patients’ ability to self-pay, but rather to

determine availability of funds to cover costs of care.

o Selecting the Self-Pay response option obligates neither the hospice nor the patient to use those

funds to pay for care, should a need to self-pay arise.

o The collection of data to complete Item A1400 should not influence the delivery of hospice services

based on the patient’s ability to self-pay for care, or based on availability of other pay sources the

patient may have.

• Code K, No payer source, if the patient does not have any of the payer sources in response options

A-I available, nor do they have any personal funds available (response option J, Self-Pay) to contribute

to healthcare expenses (services, supplies, medications, etc.) during the hospice stay.

• Code X, Unknown, if the patient is not confirmed to have any of the above payer sources in response

options A-K available to contribute to healthcare expenses (services, supplies, medications, etc.) during

the hospice stay.

• Code Y, Other, if the patient has available one or more payer sources that are not listed in responses

options A-K above to contribute to healthcare expenses (services, supplies, medications, etc.) during the

hospice stay.

Coding Tips

• Use “Code Y, Other” if the patient has a payer source available through a funded charity care program.

o Patients are considered as “patients receiving charity” if they will receive funds from a funded

charity care program and patients that have no other payer source available and are not part of a

funded charity care program.

• Use “Code K, No payer source” if a patient neither has any of the payer sources listed in A-J available,

nor are a part of a funded charity care program.

• For classifying individual commercial plans, providers should use their best judgement or follow-up

with the appropriate commercial or private contact to classify individual commercial plans. For state-specific plans (other than traditional Medicaid) or other government plans (e.g., Tricare or other VA

plans), providers should follow-up with the appropriate state or government contacts for advice on

classifying these plans.

Example

1. The patient is a Medicare beneficiary and will be using traditional Medicare directly to access the

Medicare Hospice Benefit. They also have private insurance available to them to help pay for prescriptions

as needed, as well as some personal funds.

Coding: A1400A, H, and J would all be checked.

Rationale: This item is a “Check all that apply” item. Even though Medicare will be used to access

the Medicare Hospice Benefit, the existence of a private insurance plan and personal funding should

they be needed, are also coded as existing payment sources for A1400.