License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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May 17, 2022

Value-Based Insurance Design (VBID) Model Hospice Benefit Component Overview

Beginning on January 1, 2021, CMS is testing the inclusion of the Part A Hospice Benefit within the Medicare Advantage (MA) benefits package through the Hospice Benefit Component of the Value-Based Insurance Design (VBID) Model. This test allows CMS to assess the impact on care delivery and quality of care, especially for palliative and hospice care, when participating MA plans are financially responsible for all Parts A and B benefits.

Currently, when an enrollee in an MA plan elects hospice, Fee-for-Service (FFS) Medicare becomes financially responsible for most services, while the MAO (MA Organization) retains responsibility for certain services (e.g., supplemental benefits). Under the Hospice Benefit Component of the VBID Model, participating MAOs retain responsibility for all Original Medicare services, including hospice care.

Key Policies and Requirements for CY 2022 (continued from CY 2021)

Participating MAOs must continue to cover hospice care for enrollees who choose to elect hospice through an in-network or out-of-network hospice provider
Participating MAOs continue to be prohibited from applying any prior authorization to hospice care related to the enrollee’s terminal condition
Participating MAOs must continue to pay for out-of-network hospice care at 100% of Original Medicare rates, including physician services and the service intensity add-on (SIA) payments
Participating MAOs must continue to pay for any unrelated services and/or post-hospice live discharge costs, as long as they are deemed to be appropriate and medically necessary

Billing and Claims Under the Hospice Benefit

For questions about enrollment, billing, claims, and contracting related to enrollees of participating plans, hospice providers should contact the participating MAO.
Hospice providers must continue (as they have in CY 2021) to send all notices and claims to both the participating MAO and the relevant Medicare Administrative Contractor (MAC) on a timely basis
The MAO will process payment, and the MAC will process the claims for informational and operational purposes and for CMS to monitor the Model
If you contract to provide hospice services with the plan, be sure to confirm billing and processing steps before the calendar year begins, as they may be different.

Hospice providers should keep in mind that a patient may travel for their hospice care so they may see a patient enrolled in one of the participating plans offering coverage not in their service area.

Example: A patient with coverage from a participating plan whose service area is in Ohio may travel to receive hospice care from a hospice provider in Florida. The provider should submit all notices and claims to the plan in Ohio.
The hospice continues to bill claims for informational and operational purposes to their current MAC.

Reimbursement for “Unrelated Care”

Any unrelated care associated with an enrollee’s hospice stay which is covered by a plan participating in the Hospice Benefit Component is now the financial responsibility of the participating plan
FFS Medicare should not process any claims for unrelated care for an enrollee which is covered by a plan participating in the Hospice Benefit Component

Calculation of the Aggregate Cap and the Inpatient Cap

All billing related to care provided to an enrollee who have coverage through a plan participating in the Hospice Benefit Component shall not be included in calculating a hospice’s progress towards the aggregate and inpatient cap.

Contacting the VBID Model Team

All stakeholders can reach out to the VBID Model Team with any questions, comments, or concerns about the Hospice Benefit Component at VBID@cms.hhs.gov

Resource:
CMS VBID Model Hospice Benefit Component Overview Homepage
This page provides links to VBID

Coverage
Participating Plans
Billing & Payment

Eligibility Check
Directions for Submitting Claims

Outreach & Education

Publications

Hospice Benefit Component Technical and Operational Guidance

Events
Mailings

FAQs

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Value-Based Insurance Design (VBID) Model Hospice Benefit Component Overview

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