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Introduction

Starting Jan. 1, 2022, the hospice benefit component of the Centers for Medicare & Medicaid Innovation (CMMI) Value-Based Insurance Design (VBID) model will change the Medicare Advantage member’s benefits and how hospice services are billed in certain states. The hospice VBID demonstration tests a hospice “carve-in” model that shifts risk and responsibility for hospice care from the Centers for Medicare & Medicaid Services (CMS) to Medicare Advantage Organizations (MAOs). Under the model, hospices will continue to provide the services that CMS classifies as being covered in the hospice per diem payment.

Under the hospice VBID model, in states and jurisdictions where UnitedHealthcare and their delegate WellMed have been approved to offer such benefits, WellMed will be responsible for coverage and payment of all hospice-related services for the Medicare Advantage members that were formerly covered by Original Medicare. Members will remain enrolled in Medicare Advantage while receiving hospice services.

The hospice VBID model aims to ease care transitions, improve quality and timely access to the hospice benefit, and remove barriers to both palliative and hospice care so that members may choose hospice at a more appropriate time in their care journey. Under this model, WellMed will offer additional services that may not be currently included in the Original Medicare coverage for hospice. When a member elects to enroll in an in-network hospice, additional benefits such as transitional concurrent care (i.e., transitional curative services) will be available to them — these benefits are not available if a member elects hospice with an out-of-network provider. The hospice VBID model focuses on creating a more seamless transition into end-of-life care through improved continuity and transitional care for our members during their Medicare Advantage experience.

Purpose

This document is intended to provide guidance to hospice providers serving members whose plans are included in the hospice benefit component of the Center for Medicare and Medicaid Innovation (CMMI) Value-Based Insurance Design (VBID) demonstration.

The CMMI hospice VBID model aims to achieve the following outcomes:

  • Enable a seamless continuum of care for members electing hospice care and help ensure that hospice enrollees do not need to initially decide between continuing the curative care they are receiving or enrolling into hospice care without curative services
  • Improve the quality of members’ transitions into hospice care and help ensure that members enroll in quality hospices at the most appropriate time during their care journeys
  • Foster innovative partnerships between Medicare Advantage Organizations (MAOs) and hospice providers

Scope

This model only applies to members enrolled in H4527-001 which covers the Corpus Christi service area who elect Hospice after January 1, 2022. Members who elected hospice prior to January 1 are not included in the pilot and will continue to follow the existing Hospice services under CMS.

Hospice pre-approval

WellMed does not require members to receive pre-approval for hospice care. WellMed coverage of hospice services is not conditioned on a member receiving pre-approval for hospice services. In accordance with 42 CFR § 418.22, hospice providers will continue to obtain certification of terminal illness.

Prior authorizations

Prior authorizations for hospice services are not required from participating Medicare Advantage plans.

Supportive Care

Today, and in 2022, UnitedHealthcare offers qualifying members home-based palliative care services through WellMed Specialists for Health Supportive Care. The program is available to members with advanced illness who have begun a process of progressive and significant decline. It is meant to help bridge gaps for those who are not ready and/or clinically appropriate for a hospice level of care, but need additional supportive services. The interdisciplinary care team co-manages directly with the member’s primary care provider (PCP) and specialists to manage pain, symptom relief and clinical interventions.

Unlike the Medicare hospice benefit, palliative care does not have a prognosis restriction and may be provided together with curative treatment at any state of a serious illness.

The goal of palliative care is to improve quality of life for those living with serious illness and their families and caregivers by providing specialized medical care, support and relief from the symptoms and stress of a serious illness, while allowing the necessary space and time for enrollees to understand their care choices and decide on a plan of care that best reflects their needs and wishes.

In addition to the benefits that are currently covered by MAOs today, participating VBID plans must also include palliative care and a strategy for advance care planning, both of which CMS sees as paths to improving end-of-life care. The VBID model requires that UnitedHealthcare has a strategy for engaging members in non-hospice palliative care services. The UnitedHealthcare strategy includes continuing to work with WellMed to provide home-based palliative care services for qualified members.

Referring WellMed members to a WellMed palliative care program

If it is determined that a member is not ready for hospice care, they may be a candidate for a WellMed Supportive Care program.

Specialists for Health at Morgan: Supportive Care
2401 Morgan Ave
Corpus Christi, Texas 78405
Phone: (361) 371-3710
Fax (361) 371-3444

Pre-hospice consultation

A pre-hospice consultation is designed to assist members and/or caregivers by providing information and education on end-of-life care options, including hospice. A pre-hospice consultation is an optional benefit available 24/7 to all members in participating plans. Members can receive a pre-hospice consultation by reaching out directly to their Hospice care provider. Or, to be connected to a member of the WellMed pre-hospice consult team by calling the number on the back of their insurance card, or call the pre-hospice consultation team directly at 1-361-371-3710.

What to expect during a pre-hospice consultation

The pre-hospice consultation is an optional benefit available 24/7 to all members in participating plans, regardless of if they are receiving palliative medical services. All members can access WellMed’s pre-hospice consult team by calling the number on the back of their insurance card, or by calling the pre-hospice consultation team directly at 1-361-371-3710.

Pre-hospice consultations will include topics such as:

  • General overview of hospice
  • Available services through hospice
  • Hospice enrollment process
  • Collaboration with patient’s primary care provider
  • Information about in- and out-of-network hospice providers and options
  • Value of in-network hospice providers, including:
    • Quality
    • Transitional concurrent care

The value of WellMed’s hospice network will be emphasized during the consultation, and members will be informed that transitional concurrent care services are only available when they choose an in-network hospice.

The member owns the decision to elect hospice, as well as the hospice selection. WellMed, nor the hospice can make or change the member’s hospice election.

Additional information about the voluntary pre-hospice consultation can be found within the CMMI RFA and Technical and Operational Guidance documents at innovation.cms.gov/innovation-models/vbid.

Hospice VBID model benefits for members choosing an in-network provider

Participating health plans must pay all eligible hospice claims for members who elect hospice at an in- or out-of-network hospice in 2022. However, members can receive additional benefits if they choose in-network hospices. Members can learn about their in- and out-of-network options during the pre-hospice consultation.

Notices and Claims

Under the model, Hospice Providers must follow Medicare guidelines to submit required notices and claims for payment to both the Medicare Administrative Contractor (MAC) and to WellMed. These notices include:

  • Notice of Election (NOE)
  • Notice of Termination or Revocation (NOTR)
  • Notice of Transfer

All notices and claims should be sent electronically. The method of transmission should be via electronic data interchange on the 837, directed to the Payer ID on the back of the member’s ID card.

Hospice providers are to submit both claims and notices only to the MAC if:

  • A member was actively enrolled in hospice care prior to Jan. 1, 2022
  • A member “opts out” of the MAO plan or moves into a non-participating plan. Note: The original plan will cover hospice and hospice-related services through the end of the month.

Hospice providers are to submit claims and notices to both the MAC and WellMed if:

  • The current NOE became active on or after Jan. 1, 2022
  • A member was actively enrolled in hospice before Jan. 1, 2022, revoked their hospice care and re-elected hospice on or after Jan. 1, 2022

Notice submission requirements

Notices must be submitted to both the MAC and Wellmed within the time frames outlined below. Consistent with CMS requirements, if notices are not submitted in a timely manner, the hospice provider risks payment delays and/or reduction in payment

Notice of Election

Hospice providers must submit the Notice of Election (NOE) within 5 calendar days of hospice admission to both the MAC and United.

Notice of Termination or Revocation

If a member chooses to revoke their hospice care election, the hospice provider must provide the MAC and WellMed with a Notice of Termination or Revocation (NOTR) within 5 calendar days after the effective date of discharge or revocation

A NOTR should not be used when a patient is transferred. Hospice providers must also contact the Health Care Liaison by phone to notify of discharge date and disposition within 24 hours of discharge. To do so, call 1-361-371-3710.

Notice of Transfer

If a member chooses to transfer from one hospice agency to another, the hospice agency that the beneficiary is transferring from submits a final claim. After the transferring hospice has submitted their final claim, the admitting hospice then submits a hospice Notice of Transfer.

Notification of Death

Please notify the Hospice Community Liaison by phone at 1-361-371-3710 within 24 hours of member expiration.

Billing and claims

Methodology

Under the hospice VBID model, hospice providers will provide the services that CMS classifies as being covered in the hospice per diem payment. WellMed will reimburse contracted health care professionals, according to CMS Standard Hospice Payment Methodology, based on the number of days and level of care provided during the member’s hospice election period.

How to submit claims

For members in the VBID demonstration plan that elect hospice on or after Jan. 1, 2022, CMS requires health care professionals delivering hospice services to submit hospice care claims to both WellMed and the MAC. Billing instructions can be found on the CMS hospice VBID information site (Opens in new window).

When to expect payment

WellMed is required to pay all clean claims within 30 days of receipt.

Where to call with questions about claims

For any claims-related questions and/or inquiries, providers can contact the customer service number listed on the member’s ID card.

Billing for transitional concurrent care

Hospice providers should not bill for transitional concurrent care. The providers administering the transitional concurrent care services are to bill WellMed, and WellMed will reimburse these community health care professionals for eligible transitional concurrent care services.

Additional resources for notices and claims

CMS Innovation Center Resources