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Getting hospice referral, authorization, recertification

Hospice Referrals
To initiate a hospice referral, a provider should select a TRICARE network hospice provider (when a network provider is available) and refer the patient to the hospice provider. Once the hospice receives the referral, it will contact the beneficiary for an evaluation. TRICARE does not require an authorization for the initial hospice evaluation. However, an  authorization is required to receive hospice services. Once the patient elects hospice
care, the hospice will submit an authorization request to TriWest.

Hospice Authorizations

TriWest requires the following items to be submitted at the time of initial authorization or recertification. It is the hospice provider’s responsibility to provide the documentation to TriWest.

For initial hospice authorization:
•     Hospice providers should register for the secure provider Web site at www.triwest.com/provider. The initial hospice authorization should be
submitted online.

•     The patient hospice election form (also called hospice consent), signed and dated by the
beneficiary, should be attached to the online request. TriWest does not supply this form;
each hospice has its own.

For recertification:
•     Each benefit period requires a separate authorization. To request continuation of hospice
services, only the hospice authorization needs to be submitted.

Transfer to another hospice and level of hospice

Levels of Hospice Care

There are four levels of hospice care. All four levels are approved at the time of  authorization of services. The hospice provider determines which level of care is appropriate for the patient. TriWest does not require notification when the patient moves to a different level of hospice care:

•     Routine home care
•     Continuous home care
•     Inpatient respite care (up to five days per month)
* General hospice inpatient care

Revocation/Transfer to Another Hospice

The beneficiary may choose to revoke or end hospice services at any time. They also may decide to re-elect hospice at any time, but will forfeit the remaining days for the benefit period they are in at the time they revoke. Basic TRICARE coverage will be in effect following the revocation. The hospice must submit the patient’s signed and dated
revocation form to TriWest by fax at 1-866-269-5892 (TRICARE Prime and TRICARE Standard beneficiaries) or 1-866-312-5831 (TPR, TRR, and TRS beneficiaries). The beneficiary may choose to transfer to another hospice, up to one transfer during each election period. The beneficiary will stay in the current benefit period following
the transfer. The hospice must submit the signed and dated transfer form, as well as the name of the hospice to which the care is transferred, to TriWest by fax at 1-866-269-5892 (TRICARE Prime and TRICARE Standard beneficiaries) or 1-866-312-5831 (TPR, TRR, and TRS beneficiaries).

how can find Medicare hospice program

How can someone find a Medicare-certified
hospice program?
The National Hospice and Palliative Care
Organization (NHPCO) is committed to improving
end-of-life care and expanding access to hospice
care with the goal of profoundly enhancing quality of
life for people dying in America and their loved ones.
This organization, which represents most hospice
programs in the United States, has a hospice locator
program of its members. To find an NHPCO member
hospice, call NHPCO’s HelpLine at 1-800-658-8898
or log on to their web site at www.nhpco.org/database.
htm. Other ways to find Medicare-certified
hospice programs are through state hospice associations,
state health departments, or health care professionals
and clergy.

patient stop receiving hospice care

Why would a patient stop receiving hospice care?
A hospice patient has the right to stop receiving hospice
care at any time, for any reason. If the patient
chooses to stop hospice care, health care benefits from
the standard or managed care Medicare program continue.
On occasion, a terminally ill patient’s health
improves or the patient’s illness goes into remission
while receiving hospice care. A patient’s condition
may become stable to the point that the hospice team
and physician(s) believe the patient cannot be certified
as terminally ill (having a life expectancy of six
months or less), and, therefore, is no longer eligible for
the Benefit. At any point in time, a patient can
return to hospice care, as long as the eligibility criteria
is met and certification by physician(s) and hospice
team is received.

Medicare HMO on hospice benefit will cover?

What if a patient is enrolled in a Medicare
managed care (HMO) plan?
A hospice-eligible patient who is enrolled in a
Medicare managed care plan may choose any
Medicare-certified hospice provider. Authorization
from the managed care plan is not required.
Can a patient change his or her
hospice provider?
Yes. A hospice patient has the right to change
hospice providers at any point, as long as the newlychosen
hospice program is Medicare-approved.

Medicare out of pocket for hospice care

What costs are covered and what are the
“out-of-pockets” to be paid by the patient?
Medicare pays the hospice directly for the patient’s
hospice care. Patients may have to pay no more than
5 percent — up to $5 for each prescription — for
outpatient drugs for pain relief and symptom control.
The hospice patient may also be responsible for 5
percent of the Medicare payment amount for inpatient
respite care.

Is a patient’s Medicare coverage forfeited if
hospice care is chosen?
Not at all. A patient retains full Medicare coverage
for any health care needs not related to the terminal
diagnosis, even if the patient elects hospice care. The
patient must continue to pay the applicable deductible
and coinsurance amounts under the standard Medicare
Plan or the copayment under a Medicare managed
care (HMO) plan.

How long can a patient receive hospice care?
For as long as the physicians continue to recertify the
terminal illness, patients can receive hospice care.
Two 90-day periods of care are followed by an unlimited
number of 60-day periods, as long as the patient
remains eligible. Hospice care is provided only to
patients who have been certified by their doctor and
the hospice medical director as terminally ill with a
life expectancy of six months or less.