The hospice program must enter into an agreement with TRICARE to be eligible for payment. 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 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. Note: Continuous home care must be equal to or greater than eight hours per day, midnight to midnight, with at least 50 percent of the care provided by licensed practical nursing or registered nursing staff. The rates will be adjusted for regional differences using appropriate Medicare area wage indexes.
The national 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 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.
The hospice will bill for its 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).
Independent attending physician services or patient care services rendered by a physician not under contract with or employed by the hospice are not considered a part of the hospice benefit and are not included in the cap amount calculations. The provider will bill for these services on a CMS-1500 using the appropriate CPT codes. These services will be subject to standard TRICARE reimbursement and cost-sharing/deductible provisions.
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