VBID Model Hospice Benefit Component Billing & Payment

VBID Model Hospice Benefit Component Billing & Payment

VBID Model Hospice Benefit Component Quick Links:

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For questions about enrollment, billing, claims, and contracting, contact the plan.

Eligibility Check

Here is how to determine if your patient has enrolled in a plan of a Medicare Advantage Organization (MAO) that is participating in the Value-Based Insurance Design (VBID) Model Hospice Benefit Component:

NOTE: For CY 2024, hospice providers should check if their hospice patient was enrolled in a MA plan participating in the Hospice Benefit Component in 2021, 2022, 2023 AND/OR 2024.

STEP ONE:  Confirm your patient’s Medicare eligibility and check for Medicare Advantage (MA) enrollment. If your patient shows you an MA enrollment card, move to Step 2. If your patient shows you a Medicare card with a Medicare Beneficiary Identifier, use either your normal process or any of the following online tools or services to check for MA enrollment:

  • MAC Portal
  • MAC Interactive Voice Response (IVR) System
  • Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS)
  • Billing agencies, clearinghouses or software vendors

STEP TWO:  If the patient is in an MA plan and the hospice election date is on or after January 1 of the current calendar year or any previous calendar years when the MA plan may have participated in the Model, identify the MA contract number and plan benefit package identification information on the MA enrollment card or by using one of the online tools or services in Step 1.

              It will look like this: H#######. For example, H1234-001.

Reminder: Check the effective and termination dates to ensure the patient’s enrollment in the participating plan is for 2024.

STEP THREE:  Compare the patient’s plan information to the list of plan benefit packages (PBPs) participating in the Hospice Benefit Component of the VBID Model (XLS). If their plan is part of the Model, follow the directions below for submitting claims.

Directions for Submitting Claims

Hospice providers that are not contracted with a participating MAO must submit Original Medicare claims to participating MAOs to be paid at Original Medicare rates for covered hospice care provided to participating plans’ enrollees. 

Here is how to bill for a patient enrolled in a participating MAO for hospice services:

  • Confirm the hospice election start date is on or after January 1, 2024 for new plan participants and on or after January 1, 2021 OR January 1, 2023 for returning plan participants (where calendar year(s) should align with the calendar year(s) the plan participated in the Hospice Benefit Component);
  • File the Notice of Election (NOE) with your MAC and the MAO;
    • NOTE: Hospice providers are expected to file timely NOEs to the participating MAOs. If providers do not file timely NOEs then the MAO may not cover and pay for days of hospice care from the effective date of election to the date of filing of the notice of election, as is current policy under Original Medicare. 
  • Submit claims to your MAC as you normally would. Medicare will treat these claims as informational for operational processing and monitoring and return a Remittance Advice with the following messages:
    • 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 Contractual Obligation (CO): MAOs participating in the VBID Model’s hospice benefit component will be responsible for coverage of the above services
  • Submit the claim to the MAO—if you are a hospice provider that is not in the participating MAO’s network you can use the same forms you use to submit claims to your MAC.
  • Upon hospice discharge or benefit revocation, file the Notice of Termination or Revocation (NOTR) with your MAC and the MAO.

Hospice providers that are contracted with a participating MAO should follow billing and claims processing guidelines within contractual arrangements.

For guidance around enrollment and coverage changes, please reference the CY 2021 Hospice Benefit Component Technical and Operational Guidance and the CY 2024 Technical and Operational Guidance Supplement. For assistance triaging any issues or questions with billing, please contact your patient’s MAO, your local MAC, or CMS at VBID@CMS.HHS.gov.

Page Last Modified:
09/26/2023 02:01 PM