WASHINGTON, D.C. (June 3, 2020)—As announced first in January 2019, starting in calendar year (CY) 2021 (and through CY 2024) the Centers for Medicare & Medicaid Services (CMS) will begin a demonstration program under the Value-Based Insurance Design (VBID) model to test coverage of hospice care as part of the Medicare Advantage (MA) benefit package. Under the model, participating MA plans will be responsible for payment for hospice services received by beneficiaries enrolled in the plans. While CMS will not release a list of MA organizations participating in the model until Fall of 2020 (at which time it will be available here), the agency has begun to make systems changes and issue billing guidance in anticipation of the model’s January 2021 start.

Issued in recent weeks, Change Request 11754/Transmittal 10127 outlines the role that Medicare’s Administrative Contractors (MACs) will play in the model, and accompanying MLN Matters article number MM11754 provides instruction for hospices submitting claims to the MACs for services provided to beneficiaries who have elected hospice and are enrolled in MA plans participating in the VBID-hospice model. Following are the instructions for hospice providers under the model:

  • Hospice providers will continue to submit bills to the MACs for hospice services provided to patients enrolled in participating MA plans
  • A hospice that does not contract (out–of–network provider) with a participating MA plan but provides hospice 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
  • A non-contracted hospice will be paid, at a minimum, the original Medicare rate for Medicare covered hospice services

The MLN Matters 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. The National Association for Home Care & Hospice (NAHC) will be seeking additional clarification on this and other issues.

In order to ensure appropriate payment under the model, CMS is making the following systems changes: For services provided to a beneficiary enrolled in a plan participating in the VBID-hospice model, Medicare will deny payment for all claims with dates of service during a hospice election (with a hospice election start date on or after January 1, 2021 through December 31, 2024) and upon discharge or revocation, through the end of the month. Providers must submit claims for these services to Medicare and can expect the following messaging:

  • Claim Adjustment Reason Code (CARC) 96: Non-covered charge(s)
  • Remittance Advice Remark Code (RARC) MA73: Information remittance associated with a Medicare demonstration. No payment issued under Fee-for-Service Medicare as patient has elected managed care 
  • Group Code CO