Does United Healthcare Cover Hospice?
Members who choose to get hospice care are covered by Original Medicare under Part A.
A member must choose and use a Medicare certified hospice provider(s) for care connected to a terminal disease after signing a Hospice Election Statement (issued by Medicare Hospice Providers). The capitation from CMS to United Healthcare is decreased to an administrative management fee per member per month as of the first of the month after the member elect hospice. The member is placed on administrative suspension by CMS.
The hospice provider is reimbursed directly by Medicare for care related to the terminal diagnosis. Providers should follow CMS billing guidelines and use the relevant modifiers when charging CMS.
Hospice elections can be revoked at any point in order to resume curative care. If coverage is revoked, United Healthcare will restore coverage for the member on the first of the following month, according to his or her benefit plan. After that, United Healthcare will start receiving regular capitation payments from CMS. The person reverts to original Medicare coverage prior to the start of the month and after the hospice benefit is revoked.
In the case of members seeking or receiving hospice care and services, United Healthcare is exclusively responsible for the following:
- Providing information to the member about hospice care options.
- A Medicare hospice provider will be referred to you.
- Pre-Hospice consultation/evaluation by a medical director or a hospice provider employee for members who have not yet opted the hospice benefit.
- Care and services for conditions unrelated to the member’s terminal disease are covered.
If a United Healthcare Medicare Advantage member has chosen hospice and needs medical treatment for a non-hospice disease, he or she can do one of the following:
- Take advantage of plan providers and services. In this situation, the member pays just the cost-sharing authorized by the plan, and the plan provider bills Medicare directly for Parts A and B treatments. Plan providers must charge Medicare for the member’s basic benefits, which must be paid through fee-for-service (FFS) methods. Plan providers should follow Medicare billing requirements and use the relevant modifiers when invoicing Medicare.
- Use non-plan/non-network providers and be treated as though you were on a fixed-fee schedule. If the service is neither emergent nor urgent, the member would pay the maximum FFS cost-sharing authorized.
If the treating physician authorizes it, the member utilizes a plan provider, and the member stays enrolled in the UnitedHealthcare Medicare Advantage plan, UnitedHealthcare is responsible for providing the member’s additional benefits (e.g., eyeglasses, prescription medicines).
Hospice Benefit Period:
There are two initial 90-day periods and then an unlimited number of 60-day periods. Every benefit period, a physician must certify that the member is terminally ill with a life expectancy of six months or fewer. If the member continues in hospice and does not rescind the election, the person will continue to receive hospice care for the next period. Chapter 9 of the Medicare Benefit Policy Manual explains how hospice services are covered under hospital insurance.
Items and services linked to a member’s terminal sickness, for which the hospice was established. If the illness runs its natural course, an individual is terminally sick if the medical diagnosis indicates that the individual’s life expectancy is 6 months or less. Chapter 9 of the Medicare Benefit Policy Manual explains how hospice services are covered under hospital insurance.