2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 78
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 78
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:
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 pages 19-22 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 in this Section.
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.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
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
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 pages 19-22 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 in this Section.
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.
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred (Participating/Non-participating): You pay all charges
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:
You Pay
See page 79
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 128)
- 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)
You Pay
See page 79
Hospice Care - continued on next page