Medicare HMO vs Fee for Service for Hospice Patients - Who Pays

Federal regulations require that Medicare fee-for-service Medicare Administrative Contracts (MAC) maintain payment responsibility for Medicare managed care enrollees who elect hospice. Health Home and Hospice MAC are responsible for all hospice related services and A/B MACs are responsible for all non-hospice related claims beginning on the date of the hospice election. Claims may be submitted by:

  • The hospice provider;
  • Provider treating an illness not related to the terminal condition; and
  • Attending physician, if the physician is not employed by or under contract to the enrollee’s hospice

Medicare fee-for-service retains payment responsibility after the revocation or expiration of the hospice election until the first day of the following month. Managed care plans will assume the payment responsibility as of that date for their enrolled beneficiaries.

Reference: CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.4


            Last Updated Thu, 09 Jul 2020 15:53:19 +0000