2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Hospice Care
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Hospice Care
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
Benefit Description
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
Standard Option - You Pay
See pages 90-92
Basic Option - You Pay
See pages 90-92
Benefit Description
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
Standard Option - You Pay
See pages 90-92
Basic Option - You Pay
See pages 90-92
Benefit Description
Hospice Care (cont.)
Pre-Hospice Enrollment Benefits
Prior approval is not required.
Before home hospice care begins, members may be evaluated by a physician to determine if home hospice care is appropriate. We provide benefits for pre-enrollment visits when provided by a physician who is employed by the home hospice agency and when billed by the agency employing the physician. The pre-enrollment visit includes services such as:
Standard Option - You Pay
Nothing (no deductible)
Basic Option - You Pay
Nothing
Hospice Care (cont.)
Pre-Hospice Enrollment Benefits
Prior approval is not required.
Before home hospice care begins, members may be evaluated by a physician to determine if home hospice care is appropriate. We provide benefits for pre-enrollment visits when provided by a physician who is employed by the home hospice agency and when billed by the agency employing the physician. The pre-enrollment visit includes services such as:
- Evaluating the member’s need for pain and/or symptom management; and
- Counseling regarding hospice and other care options
Standard Option - You Pay
Nothing (no deductible)
Basic Option - You Pay
Nothing
Prior approval from the Local Plan is required for all hospice services. Our prior approval decision will be based on the medical necessity of the hospice treatment plan and the clinical information provided to us by the primary care provider (or specialist) and the hospice provider. We may also request information from other providers who have treated the member. All hospice services must be billed by the approved hospice agency. You are responsible for making sure the hospice care provider has received prior approval from the Local Plan (see page 22 for instructions). Please check with your Local Plan, and/or visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, for listings of Preferred hospice providers.
Note: If Medicare Part A is the primary payor for the member’s hospice care, prior approval is not required. However, our benefits will be limited to those services listed on this page and on pages 91-92.
Members with a terminal medical condition (or those acting on behalf of the member) are encouraged to contact the Case Management Department at their Local Plan for information about hospice services and Preferred hospice providers.
Note: If Medicare Part A is the primary payor for the member’s hospice care, prior approval is not required. However, our benefits will be limited to those services listed on this page and on pages 91-92.
Members with a terminal medical condition (or those acting on behalf of the member) are encouraged to contact the Case Management Department at their Local Plan for information about hospice services and Preferred hospice providers.
Benefit Description
Covered services
We provide benefits for the hospice services listed below when the services have been included in an approved hospice treatment plan and are provided by the home hospice program in which the member is enrolled:
Standard Option - You Pay
See below
Basic Option - You Pay
See below
Covered services
We provide benefits for the hospice services listed below when the services have been included in an approved hospice treatment plan and are provided by the home hospice program in which the member is enrolled:
- Advanced care planning (see Section 10, page 152)
- Dietary counseling
- Durable medical equipment rental
- Medical social services
- Medical supplies
- Nursing care
- Oxygen therapy
- Periodic physician visits
- Physical therapy, occupational therapy, and speech therapy related to the terminal medical condition
- Prescription drugs and medications
- Services of home health aides (certified or licensed, if the state requires it, and provided by the home hospice agency)
Standard Option - You Pay
See below
Basic Option - You Pay
See below
Benefit Description
Traditional Home Hospice Care
Periodic visits to the member’s home for the management of the terminal medical condition and to provide limited patient care in the home. An episode of care is one home hospice treatment plan per calendar year. See page 90 for prior approval requirements.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member/Non-member facilities: $450 copayment per episode (no deductible)
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Traditional Home Hospice Care
Periodic visits to the member’s home for the management of the terminal medical condition and to provide limited patient care in the home. An episode of care is one home hospice treatment plan per calendar year. See page 90 for prior approval requirements.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member/Non-member facilities: $450 copayment per episode (no deductible)
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Benefit Description
Continuous Home Hospice Care
Services provided in the home to members enrolled in home hospice during a period of crisis, such as frequent medication adjustments to control symptoms or to manage a significant change in the member’s condition, requiring a minimum of 8 hours of care during each 24-hour period by a registered nurse (R.N.) or licensed practical nurse (L.P.N.).
Note: Members must receive prior approval from the Local Plan for each episode of continuous home hospice care (see page 90). An episode consists of up to seven consecutive days of continuous care. The member must be enrolled in a home hospice program in order to receive benefits for subsequent continuous home hospice care, and the services must be provided by the home hospice program in which the member is enrolled.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: $450 per episode copayment (no deductible)
Non-member facilities: $450 per episode copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Continuous Home Hospice Care
Services provided in the home to members enrolled in home hospice during a period of crisis, such as frequent medication adjustments to control symptoms or to manage a significant change in the member’s condition, requiring a minimum of 8 hours of care during each 24-hour period by a registered nurse (R.N.) or licensed practical nurse (L.P.N.).
Note: Members must receive prior approval from the Local Plan for each episode of continuous home hospice care (see page 90). An episode consists of up to seven consecutive days of continuous care. The member must be enrolled in a home hospice program in order to receive benefits for subsequent continuous home hospice care, and the services must be provided by the home hospice program in which the member is enrolled.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: $450 per episode copayment (no deductible)
Non-member facilities: $450 per episode copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Benefit Description
Inpatient Hospice Care
Benefits are available for inpatient hospice care when provided by a facility that is licensed as an inpatient hospice facility and when:
Note: Benefits are provided for up to 30 consecutive days in a facility licensed as an inpatient hospice facility. The member does not have to be enrolled in a home hospice care program to be eligible for the first inpatient stay. However, the member must be enrolled in a home hospice care program in order to receive benefits for subsequent inpatient stays.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Inpatient Hospice Care
Benefits are available for inpatient hospice care when provided by a facility that is licensed as an inpatient hospice facility and when:
- Inpatient services are necessary to control pain and/or manage the member’s symptoms;
- Death is imminent; or
- Inpatient services are necessary to provide an interval of relief (respite) to the caregiver
Note: Benefits are provided for up to 30 consecutive days in a facility licensed as an inpatient hospice facility. The member does not have to be enrolled in a home hospice care program to be eligible for the first inpatient stay. However, the member must be enrolled in a home hospice care program in order to receive benefits for subsequent inpatient stays.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible)
Non-member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: Nothing
Member/Non-member facilities: You pay all charges
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Advanced care planning, except when provided as part of a covered hospice care treatment plan (see page 90)
- Homemaker services
- Home hospice care (e.g., care given by a home health aide) that is provided and billed for by other than the approved home hospice agency when the same type of care is already being provided by the home hospice agency
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges