28 Apr Medicare Advantage and Hospice: What You Need to Know
Exploring how Medicare Advantage plans intersect with hospice operations and billing
The role of Medicare Advantage plans has grown significantly, impacting various aspects of care delivery. Understanding the nuances of these plans will have increasing importance to hospice providers as CMS moves toward its goal of shifting traditional Medicare to value based care. This article explores how Medicare Advantage plans intersect with hospice operations and billing.
Overview of Medicare Advantage Plans
According to Kaiser Family Foundation (“KFF”), in 2024, more than half of Medicare beneficiaries were enrolled in a Medicare Advantage plan. This number is projected to reach 64 percent by 2034. MA plans attract members by offering additional benefits such as vision, dental, hearing and wellness programs, and by having out of pocket limits. United Health Care and Humana have the bulk of the market share with nearly half of all MA members. According to KFF, MA plans tend to have a higher percentage of minority patients and dually eligible patients.
Unlike traditional Medicare, which allows patients to see any provider that accepts Medicare, MA plans often have limited networks, requiring their members to use specific providers. MA plans also have more prior authorization requirements than regular Medicare.
Medicare Advantage Plans and Hospice
MedPAC found that half of the beneficiaries enrolled in MA plans who died in 2022 used hospice services. Similar to hospice care, MA plans are designed to reduce overutilization of costly services, which can accumulate quickly at the end of life. This aligns MA plans as a potential referral source for hospice agencies.
Currently, there is wide variation in MA plan enrollment from state to state, and even from county to county. Consequently, MA plans impact individual hospice programs differently, and larger hospice programs may experience wide variation within their service footprint.
Special Populations
As of 2024, 20 percent of MA members were enrolled in Special Needs Plans (SNPs). SNP plans limit enrollment to specific populations, such as dually Medicare and Medicaid eligible populations and to people with chronic diseases such as diabetes, HIV/AIDS, cardiovascular conditions, and people with disabilities. SNPs serve a vital function in providing tailored healthcare services for individuals with special medical needs, including those with terminal illnesses. SNPs can streamline access to hospice care.
Some MA plans—“ISNPs”—focus on the frail elderly nursing home-based population. Hospices excel at providing care to end-of-life patients in a nursing home facility setting and are well-positioned to collaborate with ISNP plans.
While MA plans don’t directly cover hospice services, they can still impact access and transitions to hospice. Building and maintaining good relationships with MA providers impacts hospice referrals. Studies have found that MA plan membership increases the likelihood of hospice use, compared to traditional Medicare. FFS Medicare coverage of hospice care can also incentivize MA plans to refer patients to hospice earlier.
According to KFF, MA plans have a higher percentage of minority patients and dually eligible patients. Hospices have long demonstrated proficiency in providing care to populations with unique needs.
Palliative care coverage
MA plans must at least cover at a minimum the services covered by traditional Medicare, including palliative care. The extent of benefits can vary from plan to plan, with variation in cost and eligibility requirements. Authorization requirements and network limitations may also apply to the palliative care services that many hospice agencies offer.
Navigating billing: MA members in hospice
Since hospice care is carved out of MA plans, an admission to hospice reinstates traditional Medicare benefits, with the hospice billing the MAC. Challenges can sometimes arise when MA plan members receiving hospice need care for an unrelated condition. Even with traditional Medicare covering hospice care, patients may remain enrolled in their MA plan for coverage of other unrelated care. This can be confusing for hospice patients and their family members. Hospices have an opportunity to remove this barrier by developing informational materials for MA plan patients, families, and their providers.
In the event of a revocation, the patient’s care is covered by traditional Medicare until they can return to an MA plan on the first day of the month following revocation.
The VBID Experiment
In 2021, the VBID program allowed certain MA plans to “carve-in” the hospice benefit, with the goal of reducing fragmentation of end-of-life care. Providers had to submit NOEs and claims to both the plan and the MAC. CMS ended the Hospice Benefit component effective December 31, 2024, citing operational challenges for participants and lack of participation by MA plans as reasons for terminating the program for the time being.
Data Transparency
A 2024 bill called for increased data transparency around the supplemental benefits offered by MA plans. This would include the services plan members received, their providers, as well as utilization and payment data. Publicly available data would show how much palliative care and concurrent care MA members truly receive.
Medicare Advantage quality ratings do not account for end-of-life care metrics. By including these, stakeholders would have greater visibility into hospice access and disparities in care.
The Takeaway
MA plan participation affects roughly half of Medicare beneficiaries, but participation can vary widely in individual hospices providers’ markets. The intersection of MA plans and hospice presents both challenges and opportunities. MA plan participation is expected to increase, and the retirement of the VBID Hospice Benefit program leaves some uncertainty about how future innovations might affect hospice coverage for MA plan participants. Increasing data transparency will likely impact hospice referrals and hospice provider preference by MA plans.
- Selecting the best caregiver for end-of-life care
- Home care and hospice collaboration
- Best financial practices for hospice care agencies
- The keys to quality improvement in hospice agencies
- Building strong partnerships with hospice stakeholders
Alora is engineered to keep Hospice agencies running at peak efficiency. From dashboards and tools tracking the most critical components of care, to our team providing you with the highest level of agency training and support, Alora’s easy to use system streamlines clinical documentation, tracks patient care, manages billing operations, and ensures regulatory compliance.
No Comments