Skip to Content

Provider Manual

Hospice Care Coordination

Last Updated on November 16, 2018

Overview

Security Health Plan Medicare Advantage members who are appropriate for end of life palliative medical and support services will be referred to a Medicare certified hospice program for hospice care. Original Medicare, not Security Health Plan, in accordance with Medicare’s guidelines, will provide coverage for hospice care for Security Health Plan Medicare Advantage members.

Hospice patient definition

A member is eligible for hospice care only after the attending physician and the hospice medical director concur that the member is terminally ill and has a life expectancy of 6 months or less.

Hospice guidelines

A member must sign a statement choosing hospice care instead of Security Health Plan Medicare Advantage coverage for his/her terminal illness.

Care must be provided by a Medicare approved hospice. Security Health Plan Medicare Advantage members will be provided information on all Medicare approved hospice programs in the area. The member selects a Medicare certified hospice of choice.

Coverage guidelines

Medicare Advantage plan members may receive care from any Medicare certified hospice program. Original Medicare (rather than Security Health Plan) will pay the hospice provider for the services they receive.

The hospice doctor can be a network provider or an out-of-network provider. They will still be a plan member and Security Health Plan will pick up the cost share for the member that original Medicare applies, minus any cost share the member would have as an Medicare Advantage plan member.

Example: Member is on the Spirit plan and has an office visit. The claim processes through original Medicare and the member has 20 percent coinsurance. (For this example the coinsurance amount was $25.) Security Health Plan will pay $10 and the member is responsible for $15.

The claim must first go to original Medicare and then must be submitted to Security Health Plan as secondary with the Medicare EOMB attached showing what Medicare paid. If there is no EOMB attached, the claim will be denied ANSI B9.

  • A member can elect to be enrolled in hospice for an unlimited number of election periods of hospice care. The period consists of two 90-day benefit periods followed by an unlimited number of 60-day periods. Benefit periods can be used concurrently or at intervals; however, the member must be certified as terminally ill at the beginning of each benefit period.
  • A member has the right to discontinue hospice care at any time; however, any days remaining in that benefit period are forfeited.
  • A member has the right to change hospice programs one time per benefit period.
  • A Security Health Plan Advocare case manager may monitor members involved in hospice care, as  indicated.

Commercial member hospice services require prior authorization, learn more