Eli's Hospice Insider

MA plans must pay non-contracted hospices the same as FFS, for the first year.

Hospices can get some clues about reimbursement for the Medicare Advantage carve-in, but not the whole story.

The Centers for Medicare & Medicaid Services has released the 2021 Hospice Capitation Racebook and Actuarial Methodology, “finalizing the CY 2021 hospice capitation rate development methodology under the hospice benefit component of the CMS Center for Medicare and Medicaid Innovation Value-Based Insurance Design (VBID) Model,” CMS says in a message to providers. The ratebook details how much CMS will pay plans for the hospice option.

However: It doesn’t signify how much plans will actually pay hospices under the model. “Payments to hospices that contract to be in-network providers will be paid according to the contractual arrangement they arrive at directly with the MA plan,” notes the National Association for Home Care & Hospice’s Theresa Forster in a message to members.

And CMS has revealed other specifics in recently issued documents. “CMS is testing the impact on payment and service delivery of incorporating the Medicare Part A hospice benefit with the goal of creating a seamless care continuum in the MA program,” the agency says in Change Request 11754 released last month. “CMS will evaluate the impact on cost and quality of care for MA enrollees, including how the Model improves quality and timely access to the hospice benefit, and the enabling of innovation through fostering partnerships between MAOs and hospice providers,” the CR says.

“MAOs will incorporate the current Medicare hospice benefit into MAO covered benefits in combination with offering palliative care services outside the hospice benefit for enrollees with serious illness and providing individualized transitional concurrent care services,” CMS adds.

Good news: “To ensure access to hospice providers, for CY 2021, all participating MAOs must cover hospice services furnished by both in-network and out-of-network providers,” CMS instructs in the transmittal. “Participating MAOs must pay non-contracted hospice providers at a rate equal to the Original Medicare Fee-For-Service (FFS) payment for hospice services. Additionally, cost sharing for hospice services may be no higher than the cost sharing in Original Medicare for hospice benefits.”

For services provided to a beneficiary enrolled in a VBID plan, “Medicare will deny payment for all claims with dates of service during a hospice election,” CMS explains in MLN Matters article 11754. “Providers MUST still submit claims for these services to Medicare” and can expect claims codes indicating the non-covered status and demonstration, the article says.

“Hospice providers will continue to submit bills to the MACs for hospice services provided to patients enrolled in participating MA plans,” NAHC explains in its member newsletter. An out-of-network hospice that provides services to a beneficiary enrolled in the plan “will be required to submit the same billing form used to bill original Medicare to the MA plan.”

The article does not specify “whether hospice providers that contract with MA plans to be in-network providers will be required to bill the MA plan as well or if the MAC will transmit the claim information directly to the MA plan,” NAHC points out.

CMS also published a Medicare Advantage rule in the June 2 Federal Register which addresses special election periods. The rule is at www.govinfo.gov/content/pkg/FR-2020-06-02/pdf/2020-11342.pdf. The MLN Matters article is at www.cms.gov/files/document/mm11754.pdf. The ratebook is available via a link at https://innovation.cms.gov/innovation-models/vbid.