Election by Managed Care Enrollees

20.4 - Election by Managed Care Enrollees (Rev. 188, Issued: 05-01-14; Effective: 08-04-14; Implementation: 08-04-14) A managed care enrollee may elect the hospice benefit. After the hospice election, Medicare pays the hospice for hospice services and pays for services of the managed care attending physician, who may be a nurse practitioner, (as defined in section 20.1 of this chapter) and services not related to the patient’s terminal illness, through the fee-for- service system. (See 42 CFR 417.531 and 417.585.) Once under a hospice election, a managed care patient may also choose to use a provider outside of his or her managed care organization for care unrelated to the terminal illness or related conditions, or as the attending physician. See Pub. 100-04, Medicare Claims Processing Manual, chapter 11, section 40 for requirements for physician billing. Once a managed care enrollee has elected hospice, all his or her Medicare benefits revert to fee-for-service, though the enrollee still remains on managed care for any additional benefits provided by his or her managed care plan, such as dental or vision coverage. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness. Upon discharge or revocation, fee-for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive. At the start of the month following revocation or discharge, all billing and coverage revert back to the managed care plan (see Pub 100-04, Medicare Claims Processing Manual, chapter 11, §30.4).