A Value-Based Insurance Design (VBID) hospice overview: In-network vs. out-of-network providers

May 17, 2021
Categories: Home health, Hospice, Palliative care
Reading Time: 5 minutes

Commonly known as the Medicare Advantage hospice carve-in, the Value-Based Insurance Design model officially launched January 1, 2021, with 53 Medicare Advantage Plans offering the benefit in 206 counties within 13 states and Puerto Rico. In each VBID model year, CMS releases a request for application (RFA) for existing and additional Medicare Advantage organizations to participate. The calendar year 2022 RFA is currently released, and CMS is expected to publish a list of approved plans, contacts, and service areas for 2022 later this fall. If the 2022 approved plans are to offer the VBID model benefit in your hospice service area, it’s important that your agency understands the difference between in-network and out-of-network providers in order to prepare for and operationalize the model.

Here, we discuss the value-based insurance design (VBID) hospice overview, as well as take a deeper dive into the differences between in-network and out-of-network providers.

A quick overview of the VBID model

The VBID model is a CMS Innovation Center demonstration model that will run for four years, beginning with the hospice patient elections made on or after January 1, 2021. For the first time ever, the model will test the carve-in of hospice benefit into Medicare Advantage with the provision of palliative care, transitional concurrent care, and supplemental benefits.

In the first two model years, the choice remains with the patient to choose an in-network or out-of-network provider, but the Medicare Advantage plan can have a consultation with the patient prior to hospice selection to advise on the differences in benefits. It is important to note that only patients who are serviced by in-network providers will be able to access those palliative care, transitional concurrent care, and supplemental benefits.

Also, in the first two years, participating Medicare Advantage organizations may not charge higher cost-sharing for hospice services provided in-network or out-of-network than those levels permitted under Original Medicare.

In-network providers for the VBID model

Under the model, a contracted provider is a provider that enters into a written agreement with a participating plan to furnish Original Medicare and additional services to its plan enrollees. Contracted providers are also known as in-network providers. If the hospice provider has not signed a contract with a participating plan, then that provider is out of network for that plan until a network contract has been established.

While palliative care, transitional concurrent care, and supplemental benefits are available only to patients with in-network providers, traditional part A benefits will remain and will be provided by both in-network and out-of-network providers.

For in-network providers, the contract between the provider and the MA participating plan may also specify payment rates, services the provider will offer, and rules around how to bill or interact with the plan. Hospices with an in-network contract will need to follow the requirements for billing and payment agreed to in the contract between them and the participating MA plan.

If hospices do not have a contract with a VBID plan and a hospice patient chooses your agency as out-of-network, then the patient is entitled to traditional Medicare Part A benefits, and the billing requirements for submitting claims to the participating MA plan will be the same as what exists under hospice Original Medicare Part A requirements.

In-network vs. out-of-network providers 

Regardless of whether you are in-network or out-of-network, there is an existing CMS requirement that hospice providers must submit Notice of Elections, transfers, and revocation (NOE, NOC, and NOTR) transactions, and claims to both their MAC and Medicare Advantage plan. To be clear, that is double the number of claims and hospice election/transfer/revocation transactions that need to be submitted currently under the traditional Medicare hospice Part A benefit. It is not clear whether or not CMS will relax this “double submission” requirement in future model years. But until such time, it’s important for hospice providers servicing patients in this model to understand if their vendor or clearinghouse is able to submit primary Medicare hospice claims and election/transfer/revocation transactions to two different payer entities at the same time.

Since VBID contracts are not announced by CMS until the fall timeframe, there is a short window of time for hospice providers servicing patients in VBID areas to establish in-network contract relationships and operationalize the model benefit by the first of the calendar year. Therefore, to establish an in-network relationship with a VBID plan, it is strongly advised that hospice providers servicing patients in a VBID model area proactively reach out early to the VBID plan contact as soon as those contracts are announced by CMS and it is known that MA plans will offer the benefit to patients in your service area.

It is also important that hospices have the right person performing contract negotiations—someone who is not only familiar with the services your agency provides, but also equally knowledgeable of what is beneficial to the plan. The ability to present your customer satisfaction scores, your attention to HQRP measures, and how you provide quality hospice services to the patients you serve in a cost-effective manner directly impacts those plans choosing you as a partner. Also, it is extremely important that the person performing contract negotiations is well versed on the rates that are being negotiated, as well as the services you’re committing to provide that might be different than the standard hospice care your agency has provided for years.

Humana-specific VBID plan

For example, In CY 2021, in-network provider patients who are enrolled in a Humana-specific VBID plan have access to transitional concurrent care, which is required by CMS CMMI, and two additional supplemental benefits that are unique to Humana’s model.

There’s an in-home respite care that is provided by a home health aid for an eight-hour period, and also a $500 hospice care assistance allowance that can help bridge the gap for different services that might be required by that hospice patient. All three of these services are unique and different from the standard Medicare hospice service. They’re coordinated by the hospice team as well as a Humana representative, and the hospice team continues to oversee all the patient care with the same four levels of hospice care that we currently provide per the current Medicare Policy Manual.

In summary, a hospice agency that is to pursue an in-network relationship with a VBID plan will want to monitor for the CMS announcement of CY 2022 participating plans, proactively reach out to the MA VBID plan contacts early, and be your best advocate to demonstrate a valuable, mutually beneficial partnership.

How CMS will monitor MAO performance

To provide transparency and an improved beneficiary, family, and caregiver experience with end-of-life care, CMS will monitor the performance of participating MAOs based on three quality domains:

Opportunities for (VBID) hospice feedback

The Centers for Medicare & Medicaid Services welcomes feedback from hospice agencies and other stakeholders via the following methods:

  • CMS VBID model team welcomes direct feedback from providers and other stakeholders (inclusive of any complaints or issues to aid monitoring efforts as outlined in the Monitoring Guidelines) on a rolling basis via email:[email protected].
  • CMS is open to other ways to support hospices, such as a regional VBID provider workgroup structure that could meet at a predesignated frequency (i.e., quarterly).
    • Submit feedback on this regional structure and/or other ideas to CMS via [email protected]
  • Section 2.6 of CY 2022 RFA seeks stakeholder feedback on VBID network design network adequacy.
  • In addition to the evaluation of required monitoring data and reports from plans, the CMS VBID evaluation team is to initiate a randomized approach to gather further information.
    • All model participants will be required to cooperate with efforts to conduct an independent, federally funded evaluation of the Model, which may include participation in surveys, interviews, site visits, and other activities that CMS determines necessary to conduct a comprehensive formative and summative evaluation (further described in Section 4 of the RFA)

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Carolyn Dean
Carolyn Dean

Carolyn Dean joined MatrixCare as the Regulations Compliance Manager in 2014. She is responsible for monitoring CMS Medicare and Medicaid regulations in the post-acute care space to ensure company product and service solutions support compliance with new and changing regulations. Possessing over 30 years of healthcare IT experience in diverse leadership roles inclusive of customer service, quality assurance, and regulations, Carolyn has established a vast network of industry connections with various federal, state and industry entities and organizations.

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