What services are covered under the Medicare Hospice Benefit?
The Medicare Hospice Benefit (the Benefit) covers the following services as long as they relate to the terminal diagnosis and are outlined in the patient’s care plan:
• Physician services for the medical direction of the patient’s care, provided by either the patient’s attending physician or a physician affiliated with the hospice program;
• Regular home care visits by registered nurses and licensed practical nurses to monitor the patient’s condition and to provide appropriate care and maintain patient comfort;
• Home health aide and homemaker services such as dressing and bathing that address the patient’s personal care needs;
• Chaplain services for the patient and/or loved ones, if desired;
• Social work and counseling services;
• Bereavement counseling to help patients and their loved ones with grief and loss;
• Medical equipment (i.e., hospital beds);
• Medical supplies (i.e., bandages and catheters);
• Drugs for symptom control and pain relief;
• Volunteer support to assist the patient and loved ones;
• Physical, speech, and occupational therapies for the purpose of symptom control or to enable the individual to maintain activities of daily living and basic functional skills, as well as dietary counseling, as necessary to support the hospice plan of care.
What Qualifies a Patient For General Inpatient Level of Care?
General inpatient level of care may be needed for aggressive pain management requiring frequent adjustment in medications, or complicated medication delivery done by a nurse. General inpatient level of care may also be provided for symptoms such as uncontrolled nausea, vomiting or respiratory distress; uncontrolled seizures; uncontrolled agitation or delirium. It is intended as a short-term benefit until symptoms are controlled and can be adequately managed in another setting. Once controlled, the plan will be for the patient to return home or to another setting. Caregiver breakdown does not qualify the patient to access the general inpatient level of care. This type of situation may be appropriate for the short-term respite level of care.
Is there any relief for loved ones whose responsibility it is to care for the hospice patient?
Caregivers, who are family members or other loved ones responsible for taking care of the hospice patient, may, on occasion, need a break, or respite, from daily caregiving. To give the caregiver relief, respite care may be provided in a Medicare-approved facility such as a freestanding hospice facility, a nursing home or other long-term care facility, which is covered by the Medicare Hospice Benefit for up to five days at a time.
Is a patient’s Medicare coverage forfeited if hospice care is chosen?
Not at all. A patient retains full Medicare coverage for any health care needs not related to the terminal diagnosis, even if the patient elects hospice care. The patient must continue to pay the applicable deductible and coinsurance amounts under the standard Medicare Plan or the co-payment under a Medicare Advantage plan.
How long can a patient receive hospice care?
For as long as the hospice physician continues to recertify the terminal illness, patients can receive hospice care. Two 90-day periods of care are followed by an unlimited number of 60-day periods, as long as the patient continues to meet Medicare’s criteria for eligibility. Hospice care is provided only to patients who have been certified by their doctor and the hospice medical director as terminally ill with a life expectancy of six months or less.
What if a patient is enrolled in a Medicare Advantage plan?
A hospice-eligible patient who is enrolled in a Medicare Advantage plan may choose any Medicare-certified hospice provider. Authorization from the Medicare Advantage plan is not required.
Why would a patient stop receiving hospice care?
A hospice patient has the right to stop receiving hospice care at any time, for any reason, by revoking the hospice benefit. If the patient chooses to stop hospice care, health care benefits from the standard or Medicare Advantage plan continue. On occasion, a terminally ill patient’s health improves or the patient’s illness goes into remission while receiving hospice care. A patient’s condition may become stable to the point that the hospice team and physician(s) believe the patient cannot be certified as terminally ill (having a life expectancy of six months or less), and, therefore, is no longer eligible for the Benefit. In this case the patient will be discharged from hospice care. At any point in time, a patient can return to hospice care, as long as the eligibility criteria are met and certification by physician(s) and hospice team are received.
Can a patient keep their current primary care provider while receiving hospice care?
Some primary care providers or specialty physicians may choose to follow their patients’ care while the patient is on hospice. Others defer primary/attending physician care to the hospice physician. If the hospice physician serves as the attending physician, a patient may continue to see their PCP or specialist for care not related to their hospice diagnosis.
Does the Benefit cover continuous care (a special level of hospice care) at home?
Yes. Nursing care may be covered on a continuous basis during a period of crisis as necessary to manage acute medical symptoms. Continuous care is meant to be for very brief periods of time when symptoms are so severe that without it the patient would need to be hospitalized. When the crisis is resolved and symptoms are controlled, continuous care would be discontinued.