Hospice Care is for people who are terminally ill with 6-months or less to live and who have chosen hospice care for comfort, not to cure their condition.
Medicare Part A will cover virtually 100% of hospice care expenses for those who are eligible for Medicare and have been certified as terminally ill.
Even if you chose to replace Original Medicare with a Medicare Advantage Plan, your hospice benefits are covered under Medicare Part A.
Who Is Eligible for Medicare Hospice Benefits?
Does Medicare cover Hospice Care? Yes, but there are certain rules to be met for this end-of-life care.
Medicare hospice benefits are available to individuals who are eligible for Medicare Part A (hospital insurance) and who have been certified as terminally ill by a hospice medical director and their personal physician.
To be eligible for hospice benefits under Medicare coverage, an individual must have a life expectancy of 6 months or less if the terminal illness runs its normal course.
You must need hospice care for comfort, not for curative treatment.
The patient must also sign a statement choosing hospice care instead of other Medicare-covered treatments for their terminal illness.
In addition, the individual must receive care from a Medicare-approved hospice program, which provides palliative care (treatment to alleviate pain and discomfort) and support services, including counseling and spiritual care for`11 ` the individual and their family. It can be in inpatient hospice houses, an inpatient hospice center, etc.
What Services Are Included in Hospice Care?
Depending on your individual situation, your hospice plan of care might include any or all of these hospice services, developed by your hospice medical team:
• Doctors’ services
• Occupational therapy services
• Skilled therapy services
• Nursing and medical services in a skilled nursing facility, nursing homes, etc.
• Drugs for pain management during terminal illness and related conditions for the patient’s hospice care
• Medical supplies
• Social services
• Dietary counseling
• Speech-language pathology services
• Spiritual and grief counseling for you and your family
• Short-term inpatient care for pain and symptom management
• Inpatient respite care (which you get in a Medicare-approved facility – a hospital inpatient facility, hospital, or nursing home – so that your usual caregiver can have a rest)
• Any other Medicare-certified hospice care to handle your pain and other symptoms related to your specific condition if you’re terminally ill.
What Are Medicare Requirements for Hospice Care?
Medicare sets specific requirements for hospice care to ensure that a terminally ill patient receives high-quality, comprehensive care that addresses their physical, emotional, and spiritual needs during the end-of-life phase, like pain relief, etc.
Here are some of the requirements:
1) Certification of terminal illness and related conditions
A hospice physician and hospice medical director must certify that a beneficiary has a life expectancy of 6 months or less if the illness runs its natural course.
2) Election statement
The beneficiary must sign a statement choosing Medicare hospice coverage care instead of other Medicare-covered treatments for their terminal illness.
3) Medicare-approved hospice provider
The beneficiary must receive care from a Medicare-approved hospice provider (like a skilled nursing facility or hospice inpatient facility), which provides palliative care and support services to hospice patients.
4) Care plan
A hospice team, including a physician, nurse, social worker, chaplain, and other specialists, must create and update an individualized care plan for the beneficiary.
5) 24/7 access to care
The hospice provider must have the hospice team available to provide care 24 hours a day, 7 days a week.
6) Comprehensive services
The hospice provider must provide a range of services, including medical care, pain management, counseling, spiritual care, and bereavement support.
7) Coordination of care
The hospice provider must coordinate care with the beneficiary’s other healthcare providers to ensure that the individual’s needs are met.
8) Quality reporting
The hospice provider and hospice team must report data to Medicare on quality measures, including pain management and patient satisfaction.
Does Medicare Cover Respite Care?
Yes, Medicare covers respite care as part of the hospice benefit. Respite care is designed to give caregivers a break from their caregiving responsibilities so that they can rest and recharge.
Medicare benefits cover up to 5 days of respite care at a time, which can be provided in a hospice facility or a hospital.
To qualify for respite care, the hospice doctor must determine that the caregiver needs a break and that respite care is necessary to provide the best care for the beneficiary.
During respite care, the beneficiary stays in a Medicare-approved hospice house and receives room and board, as well as any necessary medical services.
Medicare Advantage Plans and Hospice Care Benefits
Medicare Advantage plans are required by law to provide the same hospice care benefits to a hospice patient as Original Medicare benefits. This means that if you are enrolled in a Medicare Advantage plan and you become eligible for hospice care, you will receive the same hospice care services from hospice providers as someone enrolled in Original Medicare.
If you are enrolled in a Medicare Advantage plan and you choose to receive hospice care, your hospice benefit will be covered under Original Medicare, not your Medicare Advantage plan. However, your Medicare Advantage plan may still provide additional benefits, such as prescription drugs coverage, that are not covered under Original Medicare.
How Long Will Medicare Pay for Hospice Care?
Medicare will pay for hospice care as long as the beneficiary continues to meet the eligibility criteria for Medicare’s hospice benefit. This means that as long as a hospice doctor and the individual’s physician certify that the individual is terminally ill with a life expectancy of 6 months or less if the illness runs its natural course, and the individual continues to choose hospice care over other Medicare-covered treatments, Medicare will continue to pay for hospice.
However, hospice care is not a “long-term benefit”. It is intended to provide care and support during the final months of life. If an individual’s health improves or their illness stabilizes, they may no longer be eligible for hospice care.
If this happens, the individual’s provider will work with their physician to determine if they should be discharged from hospice care and if other Medicare-covered treatments should be pursued.
Hospice care has a benefit period, which is typically 90 days in length. At the end of each 90-day period, the hospice provider will review the individual’s condition and determine if they are still eligible for hospice care.
If the individual continues to meet the eligibility criteria, their hospice benefit will be renewed for an additional 90-day period. This process continues as long as the individual remains eligible for hospice care.
How Much Do We Pay for Hospice?
In general, Medicare covers hospice care services with no out-of-pocket costs for the beneficiary or their family, as long as the care is provided by a Medicare-approved hospice provider and the individual meets the eligibility requirements.
Under the Medicare hospice benefit, hospice care includes all services related to terminal illness, including medical care, pain management, counseling, and support services. These services are covered by Medicare Part A, and there are no deductibles or co-payments for hospice care.
However, some services that are not related to the terminal illness may not be covered, and beneficiaries may be responsible for these costs.
For example, if the beneficiary requires treatment for a condition unrelated to the terminal illness, such as a broken bone or the flu, they may need to pay for those services out of pocket or through their Medicare Part B coverage.
A co-payment of up to $5 applies for each prescription for outpatient drugs for pain and symptom management.
If the hospice benefit doesn’t cover your drug (which is rare), your hospice provider will contact your plan to see if Part D covers it. The hospice provider will let you know whether any drugs or services aren’t covered and if you’ll need to pay for them out of pocket.
A 5% of the Medicare-Approved Amount for inpatient respite care may be another additional cost.
Also, if the beneficiary chooses to receive hospice care in a facility, such as a hospice facility or a nursing home, Medicare doesn’t cover room and board costs. There may be a short-term exception to this if room and board is needed for respite care.
Matthew Claassen, CMT and CEO of Medigap Seminars Insurance Agency.
Medigap Seminars is an award winning premier national Medicare Insurance Brokerage, ranked among the top in the U.S.A. Matthew is considered a leading national expert on Medicare and Social Security. Mr. Claassen is a distinguished member of the Forbes Business council, an invitation only organization of business leaders and entrepreneurs. He and his team have received awards from many of the countries largest insurance companies including Mutual of Omaha, Aetna, Humana, Cigna, United American, United Healthcare and others. His videos have become the most popular Medicare educational videos on YouTube with millions of views.
As a financial analyst Matthew lead a team of researchers to win the 2009 Best Equity Research & Strategy Award from The Technical analysis magazine.
Disclaimer: Medicare has neither reviewed nor endorsed this information. Medigap Seminars Insurance Agency is not connected with or endorsed by the United States Government or the Federal Medicare program. Medigap Seminars Insurance agency offers Medicare supplement, Medicare Advantage, Part D prescription drug coverage and related life and health insurance products.
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