Hospice services are covered for Commercial, Medicaid, Family Health Plus and Child Health Plus plan members. Medicare members requiring hospice services have the benefit covered by original (non-managed) Medicare.
The hospice benefit is provided primarily at home, although it does not come under the home care benefit. Secondary places of service are skilled and inpatient hospital facilities for those hospice patients who have special needs that require such an inpatient facility admission.
Although the treating physician is responsible for arranging hospice services for the patient, we will continue to coordinate all non-hospice-related services (i.e., those not related to the terminal illness for the Commercial, Medicaid, Child Health Plus, Family Health Plus or Medicare member. Therefore, to better service our members we need to have a copy of the signed Hospice Election Form and/or Hospice Revocation Form submitted to EmblemHealth's Care Management department. The form(s) should also include the member's name and the plan ID number.
A copy of the Hospice Election Form or Hospice Revocation Form can be mailed or faxed to:
Dignified Decisions Program
55 Water Street
New York, NY 10041-8190
Fax: 1-646-733-9312 or 1-646-733-9324
Prior Approval for Admission to Hospice Agencies or Inpatient Facilities
Hospice agencies or inpatient facilities receiving Commercial, Child Health Plus and Family Health Plus patients who have not been given prior approval should contact EmblemHealth's Prior Authorization department at 1-866-447-9717 to obtain or verify the approval prior to admitting the member to the service or facility. (See the Dispute Resolution chapters of this manual for guidelines regarding claims submitted without prior approval.)
The hospice representative must have the following information available when contacting EmblemHealth:
- Member ID number
- Member name
- Admission date
- The physician's signed attestation that the member has six months or less to live
The physician (PCP or consultant) attending the patient must attest by a certificate of medical necessity (CMN) to the patient's requirement for hospice placement and the need for palliative care. If the hospice agency or facility does not have this documentation the treating physician or hospital discharge planner must contact the plan. A letter will be sent to the hospice specifying the level and number of units (days) approved. The hospice may call Customer Service for any plan member. The hospice may also check status of a HIP member's case by signing in to www.emblemhealth.com.
Timeliness in obtaining approval ensures appropriate claims payment. Failure to get prior approval will result in the claim being denied. Please see the Dispute Resolution chapters of this manual.
Care Provided During Hospice Election Period
Hospice agencies or facilities are responsible for all care related to the terminal illness during the period of hospice election for Commercial, Child Health Plus and Family Health Plus members. This includes emergency and non-emergency situations. EmblemHealth must be notified of all care provided to the member.
To modify the level of hospice care (e.g., from home care to inpatient), medical necessity must be reviewed.
Hospice agencies or facilities that fail to provide clinical updates and/or progress notes to the Continuing Care Manager will not be reimbursed for unauthorized days.
Admission into a hospital does not automatically revoke the hospice election. As stated above, hospital admissions during the hospice election period are the financial responsibility of the hospice agency unless the member signs a Hospice Revocation Form.
If an emergency occurs and the member must be transported by ambulance to a hospital, the hospice agency or inpatient facility must notify the member's plan by calling Customer Service immediately, or as soon as possible thereafter. In the event that circumstances prevent immediate contact with the plan, the agency or facility should take all medically appropriate actions to safely transport the member to the nearest hospital.
Note: For Medicare members receiving hospice services, any care not related to the terminal illness should be balance billed to EmblemHealth.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
Formal acceptance as an inpatient by an institution, hospital or health care facility.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
A medical or behavioral condition with a sudden onset. It manifests with symptoms of such severity that a prudent layperson with an average knowledge of medicine and health could reasonably expect that the absence of immediate medical attention would result in:
- Placing the health of the afflicted person in serious jeopardy
- Placing the health of an individual with a behavioral health condition or others in serious jeopardy
- Causing serious impairment of the individual's bodily functions
- Causing serious dysfunction of any bodily organ or part
- Causing serious disfigurement of the afflicted individual
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as ID Number.
A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.