Hospice programs are not eligible for TRICARE reimbursement unless they enter into an agreement with TRICARE. National Medicare hospice rates will be used for reimbursement of each of the following levels of care provided by, or under arrangement with, a Medicare-approved hospice program:
- Routine home care
- Continuous home care
- Inpatient respite care
- General inpatient care
The national Medicare payment rates are designed to reimburse the hospice for the costs of all covered services related to the treatment of the beneficiary’s terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of, or working under arrangements made with, the hospice. The only amounts that will be allowed outside of the locally adjusted national payment rates and not considered hospice services will be for direct patient-care services rendered by either an independent attending physician or a physician under contract with the hospice program.
When billing, hospices should keep in mind the following:
- Bill for physician charges/services (physicians under contract with the hospice program) on a UB-04 using the appropriate revenue code of 657 and the appropriate CPT codes.
- Payments for hospice-based physician services will be paid at 100 percent of the TRICARE-allowable charge and will be subject to the hospice cap amount (calculated into the total hospice payments made during the cap period).
- Bill independent attending physician services or patient-care services rendered by a physician not under contract with or employed by the hospice on a CMS-1500 using the appropriate CPT codes. These services will be subject to standard TRICARE reimbursement and cost-sharing/deductible provisions, and will not be included in the cap amount calculations.
The hospice will be reimbursed for the amount applicable to the type and intensity of the services furnished to the beneficiary on a particular day. One rate will be paid for each level of care, except for continuous home care, which will be reimbursed based on the number of hours of continuous care furnished to the beneficiary on a given day.
Reimbursement may be extended for routine and continuous hospice care provided to beneficiaries residing in nursing home facilities (i.e., physician, nurse, social worker, and home health aide visits to patients requiring palliative care for terminal illnesses). TRICARE will not pay for the room and board charges of the nursing home.
Continuous home care must be equal to or greater than eight hours per day, midnight to midnight, and more than half of the care must be provided by either a registered or licensed practical nurse. The rates will be adjusted for regional differences using appropriate Medicare area wage indexes.