2020 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


Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.
 
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.


You Pay
See pages
81-82
 
Benefit Description
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
You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Participating/Non-participating): You pay all charges


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.
 
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:
  • Advanced care planning (see Section 10, page 131)
  • 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 82
 
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 20 for prior approval requirements.

*Prior approval is required

You Pay
Preferred: Nothing (no deductible)

Non-preferred (Member/Non-member): 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 20). 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.

*Prior approval is required

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Member/Non-member): 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:
  • 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.

*Prior approval is required

You Pay
Preferred: 30% of the Plan allowance

Non-preferred (Member/Non-member): You pay all charges
 
Benefit Description
Not covered:
  • Advanced care planning, except when provided as part of a covered hospice care treatment plan (see page 81)
  • 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

You Pay
All charges
 

List Item:

hospice
care
pre-hospice
prior
approval
medicare
terminal
conditions
case
management
advanced
dietary
durable
medical
equipment
rental
DME
social
services
nursing
therapy
physician
physical
occupational
prescription
health
aids
certified
licensed
registered
practical
R.N.
L.P.N
local
inpatient
death
imminent
relief
respite
homemaker
home