TRICARE has adopted most of the provisions currently set out in Medicare’s hospice coverage benefit guidelines, reimbursement methodologies, and certification criteria for participation in the hospice program. The hospice benefit is designed to provide palliative care to individuals with prognoses of less than six months to live if the terminal illness runs its normal course. Hospice care emphasizes supportive services, such as pain control and home care, rather than cure-oriented treatment.
Initiating Hospice Care
The patient, the PCM, or a family member acting on the patient’s behalf can initiate hospice care, but the hospice will not begin services without a doctor’s order. Patients must complete an “election statement,” which the hospice provides, that indicates the patient’s understanding of what hospice care involves. This statement is then filed with Humana Military. Patients must be registered in the Defense Enrollment Eligibility Reporting System (DEERS) to be eligible for and initiate hospice care. No authorization is required for a hospice evaluation. If the patient does not meet criteria for admission for hospice services, the provider cannot bill TRICARE. If the beneficiary qualifies for and accepts hospice services, the hospice must request prior authorization from Humana Military.
Hospice care is provided in three benefit periods. The first two benefit periods are each 90 days long and begin on the day that the beneficiary signs the hospice election statement and both the attending physician and the hospice medical director sign the physician’s certificate of terminal illness. The final benefit period consists of an unlimited number of 60-day periods, each of which requires recertification of the terminal illness. If a beneficiary revokes a hospice election, he or she forfeits any remaining days in that election period.
The TRICARE hospice benefit covers four levels of care: routine home care, continuous home care, inpatient respite care, and general hospice inpatient care.
Note: Respite care is covered when necessary and is limited to no more than five days at a time. General inpatient care is limited to varying short-term stays.
Levels of care will be determined by the Medicare-certified hospice agency. One of these levels of care will be in use at all times, and patients may shift among all four, depending on their needs, the needs of family members caring for them, and medical-team determinations.
Care may include:
- Counseling
- Medical equipment, supplies, and medications
- Medically necessary short-term inpatient care
- Medical social services
- Nursing care
- Other covered services related to the terminal illness
- Physical- and occupational-therapy services
- Physician services
- Speech and language pathology
Once patients elect hospice care, their care is managed by the medical director of the hospice and by the interdisciplinary clinical team managing the case, always in consultation with patients and their families. PCMs may stay involved and participate in the clinical team, as well as manage any acute needs outside hospice coverage.
A beneficiary who elects to receive care under a hospice program cannot receive other TRICARE services/benefits related to the treatment of terminal illness for which hospice is elected unless the hospice care has been formally revoked. The hospice care benefit allows for home health aid and personal-comfort items, which are limited under TRICARE’s main coverage programs. However, services for an unrelated condition or injury, like a broken bone or unrelated diabetes, are still covered as regular TRICARE benefits.
Hospice Care Settings
Patients may receive hospice care in a number of settings: at home, in a hospice facility, in a SNF, or in an MTF. Care can shift among these settings without affecting the hospice benefit or requiring an additional hospice authorization. Inpatient respite care may be available at an appropriate hospice location and is considered part of the hospice benefit for up to five days on an occasional basis.
Note: There are no deductibles under the hospice benefit. The individual hospice may charge cost-shares for items that the basic TRICARE program does not cover, such as medications, biologicals, and inpatient respite care.
Exclusions
There is no reimbursement for room-and-board charges for a patient who is receiving hospice services in the home. Room and board is not a covered hospice benefit when a patient is placed in a facility, such as a rest home, and the care is custodial. Hospice patients cannot receive other TRICARE services/benefits (curative treatments related to the terminal illness) unless they formally revoke hospice care. TRICARE only covers care that the hospice provides or arranges.
To formally revoke the hospice election, the beneficiary must submit a signed, dated statement to the hospice provider. If the beneficiary revokes hospice, he or she forfeits the remaining days in the election period. At a later time, the beneficiary may initiate hospice coverage for any other election periods for which he or she is eligible. The hospice patient may change hospice providers only once per election period.
For more information about hospice care, access Chapter 11 of the
TRICARE Reimbursement Manual.
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