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. This type of 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 their understanding of what hospice care involves. This statement is then filed with Humana Military. Patients must be enrolled 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.
Hospice care is provided in three benefit periods. The first two benefit periods are each 90 days long and begin on the day that a hospice election statement is signed by the beneficiary and a physician’s certificate of terminal illness is signed by both the attending physician and the hospice medical director. The final benefit period comprises 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.
There are four levels of care within the hospice benefit:
- Routine home care
- Continuous home care
- Inpatient respite care
- General hospice inpatient care
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 can shift among all four, depending on their needs and the needs of family members who are supporting them. Care within these levels may include physician services, nursing care, counseling, medical equipment, supplies, medications, medical social services, physical and occupational services, speech and language pathology, and hospice short-term acute patient care related to the terminal illness.
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. Because hospice care emphasizes supportive services, such as pain control and home care, rather than cure-oriented treatment, the 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 a regular TRICARE benefit.
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. Patients also cannot receive other TRICARE services/benefits (curative treatments related to the terminal illness) unless the hospice care is formally revoked. No care for the illness is covered by TRICARE unless the hospice provides it or arranges for it.
To formally revoke the hospice election, the beneficiary must submit a signed, dated statement through the hospice provider. If the beneficiary chooses to revoke hospice, he or she forfeits the remaining days in the election period, but at any time may elect to receive hospice coverage for any other hospice election periods for which he or she is eligible. The patient receiving hospice services may transfer from one hospice provider to another hospice provider only one time during each election period.
Hospice Care Settings
Hospice care can be provided in a number of settings: at home, in a hospice facility, in an 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 a cost-share for those items not allowed by the TRICARE program, such as medications, biologicals, and/or inpatient respite care.
For more information about hospice care, access Chapter 11 of the
TRICARE Reimbursement Manual.
Back to Top
