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Election of the Medicare Hospice Benefit While Receiving Home Health Services During an MA Plan Enrollment Period

According to the Medicare Claims Processing Manual, (CMS Pub. 100-04, Ch. 11, § 30.4External PDF), Medicare Fee-for-Service (FFS) contractors maintain payment responsibility for managed care enrollees who elect hospice.

When a beneficiary, who is enrolled in an MA plan, elects the Medicare hospice benefit, all services, including services provided by HHAs that are not related to the beneficiary's terminal diagnosis, are billed to the Medicare administrative contractor (MAC); not the MA plan. Services furnished after the beneficiary revokes or is discharged from hospice care will continue to be paid by the MAC until the first day of the month after the hospice election ends, at which time the MA plan resumes payment responsibility for the beneficiary.

In addition to reviewing the eligibility systems for a beneficiary's enrollment in an MA plan, HHAs should also be reviewing the hospice benefit period information to determine if the patient has elected the Medicare hospice benefit for the same time period. See the CGS Checking Beneficiary Eligibility web page for more information about the systems available to providers to check Medicare beneficiary eligibility information.

Since beneficiaries can continue to receive medical care from other health care providers for illnesses unrelated to the terminal diagnosis, it may be necessary for your HHA to contact the hospice to ensure that the services, which your HHA anticipates providing, are unrelated to the terminal illness.

If your HHA provides services to hospice patients that are unrelated to their terminal diagnosis, ensure condition code "07" is entered in the first available COND CODES field (FL 18-28) which can be found on FISS page 1 (see the example below). Condition code "07" can only be used when the services are unrelated to the terminal diagnosis; any other use of condition code "07" may be considered abusive.

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Updated: 12.11.18

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