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Understanding the Medicare Hospice Benefit

The Medicare hospice benefit, initiated in 1983, is covered under Medicare Part A (hospital insurance). Medicare beneficiaries who choose hospice care receive a full scope of medical and support services for their life-limiting illness. Hospice care also supports the family and loved ones of the person through a variety of services.

More than 90% of hospices in the United States are certified by Medicare. 80% of people who use hospice care are over the age of 65 and are thus entitled to the services offered by the Medicare hospice benefit. This benefit covers virtually all aspects of hospice care with little out-of-pocket expense to the person or family. In addition, most private health plans and Medicaid in 47 States and the District of Columbia cover hospice services.

Sometimes a person’s health improves, or their illness goes into remission. If that happens, your doctor may feel that you no longer need hospice care. Also, you always have the right to discontinue hospice care for any reason. If you stop your hospice care, you will receive the type of Medicare coverage that you had before electing hospice. If you are eligible, you can go back to hospice care at any time.

Medicare Eligibility

You can get Medicare hospice benefits when you meet all of these conditions:

• You are eligible for Medicare Part A (Hospital Insurance).
• Your doctor and the hospice medical director certify that you have a life-limiting illness and have 6 months or less to live if your illness runs its normal course.
• You sign a statement choosing hospice care instead of other Medicare-covered benefits to treat your terminal illness. (Medicare will still pay for covered benefits for any health problems that aren’t related to your terminal illness).
• You get care from a Medicare-approved hospice program.

What Medicare Covers

Medicare defines a set of hospice core services, which means that hospices are required to provide these set of services to each person they serve, regardless of the person’s insurance. Medicare will cover the hospice care you get for your terminal illness, but the care you get must be from a Medicare-approved hospice program.

Important: Medicare will still pay for covered benefits for any health problems that aren’t related to your terminal illness, like care for an injury. Medicare covers these hospice services when they’re needed to care for your terminal illness and related condition(s):

• Doctor services
• Nursing care
• Medical equipment (hospital bed, wheelchairs, walkers, etc.)
• Medical supplies (adult briefs, gloves, etc.)
• Medications for symptom control or pain relief
• Hospice aide and homemaker services
• Physical and occupational therapy
• Speech-language pathology services
• Social worker services
• Dietary counseling
• Grief and loss counseling for you and your family
• Short-term respite care
• Short-term inpatient care (for pain and symptom management)
• Any other Medicare-covered services needed to manage your pain and other symptoms related to your terminal illness, as recommended by your hospice team

The hospice benefit allows you and your family to stay together in the comfort of your home unless you need care in an inpatient facility. If the hospice team determines that you need inpatient care, the hospice team will make the arrangements for your stay.

What Medicare Won’t Cover

When you choose hospice care, you’ve decided that you no longer want care to cure your life-limiting illness, and/or your doctor has determined that efforts to cure your illness aren’t working. Medicare won’t cover any of these once you choose hospice care:

• Treatment intended to cure your terminal illness
  Talk with your doctor if you’re thinking about getting treatment to cure your illness. As a hospice patient, you always have the right to stop hospice care at any time.
• Prescription medications to cure your illness (rather than symptom control or pain relief)
• Care from any hospice provider that wasn’t set up by the hospice medical team
  You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different provider unless you change your hospice provider. However, you can still see your regular doctor if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.
• Room and board
  Medicare doesn’t cover room and board if you get hospice care in your home or if you live in a nursing home. However, if the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility.
• Care in an emergency room, inpatient hospital care, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness. 

Note: Contact your hospice team before you get any of these services, or you might have to pay the entire cost.

Election Periods

The Hospice Medicare Benefit provides coverage:

• In sequential time periods: 90 days, 90 days, and unlimited 60 days.
• When the hospice Medical Director certifies the patient as eligible for the Hospice Medicare Benefit at the start of each election period.
• When a patient waives traditional Medicare reimbursement in lieu of the Hospice benefit at a time by signing the Hospice Medicare Benefit Revocation form, thereby becoming ineligible to use the Hospice Medicare Benefit again for the remainder of the election period in which they withdraw. The patient is free to select a different Medicare-certified hospice program once during an election period.

Stopping Hospice Care

If your health improves or your illness goes into remission, you no longer need hospice care. Also, you always have the right to stop hospice care at any time for any reason. If you stop your hospice care, you’ll get the type of Medicare coverage you had before you chose a hospice program (like treatment to cure the terminal illness). If you’re eligible, you can go back to hospice care at any time.

Your Medicare Rights

As a person with Medicare, you have certain guaranteed rights. If your hospice program or doctor believes that you’re no longer eligible for hospice care because your condition has improved and you don’t agree, you have the right to ask for a review of your case. Your hospice should give you a notice that explains your right to an expedited (fast) review by an independent reviewer hired by Medicare, called a Quality Improvement Organization (QIO). If you don’t get this notice, ask for one.

Note: If you pay out-of-pocket for an item or service your doctor ordered but the hospice refuses to give you, you can file a claim with Medicare. If your claim is denied, you can file an appeal.

Medicare and insurance benefits can be complicated. The specialists at Community Healthcare of Texas are available to answer any questions you may have and help ensure you receive the benefits to which you are entitled. 

Additionally, Community Healthcare of Texas is a not-for-profit organization, and thanks to the generosity of our donors, we are committed to ensuring every patient and family has access to compassionate end-of-life care services, regardless of their ability to pay. 

For answers to questions about your specific situation, please contact us at 800.958.4942.

 

 

 

 

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