Appeal type: Hospice
Decision: Partially Favorable

 
We decided that the Plan has to pay for home health services provided from February 2, 2021, through 
March 1, 2021. We decided that the Plan does not have to pay for home health services provided from 
January 31, 2021, through February 1, 2021.  
 
You asked the Plan to pay for home health services. You say that the patient was discharged from hospice on 
January 16, 2021, and your agency started home health services on January 31, 2021. The Plan denied your 
request. The Plan says that Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the members terminal condition. The Medicare hospice benefit, through fee-
for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or 
revocation. During the election, fee-for-service Medicare also covers attending physician services and all care 
unrelated to the terminal illness until the first day of the month following the month in which hospice was 
revoked or discharged. 
 
We decided that the Plan has to pay for home health services provided from February 2, 2021, through 
March 1, 2021.  
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 15, 2021. The dates of service February 2, 2021, 
through March 1, 2021 were not provided before the end of that month. Medicare covers attending physician 
services and all care unrelated to the terminal illness until the first day of the month following the month in 
which hospice was revoked or discharged. Therefore, we decided that the Plan has to pay for home health 
services provided from February 2, 2021, through March 1, 2021. 
 
We also decided that the Plan does not have to pay for home health services provided from 
January 31, 2021, through February 1, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 15, 2021. The dates of service January 31, 2021, 
through February 1, 2021 were provided before the end of that month until the first day of the month following 
the month in which hospice was revoked or discharged. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from January 31, 2021, through February 1, 2021. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.