Does Medicare Cover Hospice Care?
If you’re wondering if Medicare covers hospice, the short answer is yes. For those who may be facing a terminal diagnosis with a life expectancy of 6 months or less, Medicare Part A could provide hospice care. This article will explain the scope of this coverage, including who qualifies, what may be included, and any potential costs, so you can make informed decisions during this challenging time.
Key Takeaways
- Medicare will likely cover hospice care under Part A for terminally ill patients, prioritizing comfort over curative treatment, with coverage that could be extended indefinitely in six-month periods subject to ongoing eligibility.
- The potential Medicare hospice benefit may include comprehensive services for pain management, symptom control, medical equipment, and counseling, although beneficiaries may incur some costs such as 5% coinsurance for drugs and copayments for outpatient drugs and inpatient respite care.
- Hospice care under Medicare will likely have no time limit; it could provide initial coverage for two 90-day periods followed by unlimited 60-day extensions, with certain services excluded, such as room and board, curative treatments, and services by non-hospice providers.
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Medicare's Hospice Coverage
Medicare may cover hospice care under its Part A, possibly making medicare cover hospice care for terminally ill patients with a life expectancy of six months or less, who choose comfort care over curative treatment. The hospice program has been designed to prioritize the patient’s comfort, focusing on pain management and symptom control rather than curative interventions.
Patients must obtain certification of their terminal illness from a hospice doctor and their physician to qualify for the hospice benefit. They must also sign a statement electing hospice care over other Medicare benefits for treating their terminal illness and related conditions. Medicare’s hospice coverage may be extended indefinitely in six-month increments, as long as the patient continues to meet the eligibility criteria.
Services Included in Medicare’s Hospice Benefit
The Medicare hospice benefit will likely include a wide range of services that could be designed to enhance patient comfort and support their families. These services may fall into three main categories: pain management and symptom control, medical equipment and supplies, and counseling and support services.
Pain Management and Symptom Control
Pain management and symptom control will likely form the cornerstone of hospice care. The goal will likely be to enhance patient comfort, alleviating pain and other symptoms that may be associated with the terminal illness.
The hospice care team may also collaborate to develop a personalized plan that addresses the patient’s specific needs, which may include medication management, non-pharmacological interventions, and emotional and psychological support.
Medicare will likely cover the cost of medications required for symptom management in hospice care. Some of Medicare’s hospice benefits may also include coverage for any prescription drugs required for pain and symptom management related to the terminal condition. The attending medical professional will work with the hospice team to determine the appropriate medications for each patient.
Also, specific non-pharmacological options for pain management in hospice care may be covered by Medicare.
Medical Equipment and Supplies
In addition to pain management, Medicare’s hospice benefit might encompass coverage for medical equipment and supplies necessary for alleviating pain and managing symptoms. This may include:
- Durable medical equipment
- Bandages
- Wound dressings
The hospice care team, which may include a nurse practitioner, will likely determine the appropriate equipment and supplies for each patient.
Patients may also have some financial responsibilities. There could be at least a 5% coinsurance requirement for drugs or biologicals covered by Medicare. Additionally, patients may be responsible for a copayment for outpatient drugs used for pain and symptom management.
Furthermore, Medicare will likely provide coverage for specific durable medical equipment after it has paid at least 80% of the approved amount. Medical equipment and supplies may also be replaced or updated as needed under Medicare’s hospice coverage, which could maintain continuous pain relief and symptom management for the patient.
Counseling and Support Services
Emotional and psychological support, alongside physical care and symptom management, could also play a vital role in hospice care. Medicare’s hospice benefit might include counseling and support services that could be accessible to both patients and their families.
Grief counseling is especially important, as it could provide mental health services to those struggling with the impending loss of their loved one. Patients and families may access counseling and support services by meeting the eligibility criteria for Medicare Part A and choosing hospice care. This counseling could potentially be extended for a maximum of one year after the patient’s death, with sessions scheduled as necessary.
Levels of Hospice Care and Payment Rates
There may be four levels of hospice care that Medicare could cover:
- routine home care
- continuous home care
- general inpatient care
- and respite care
These levels will likely be determined based on the patient’s needs and condition. Medicare may also determine the daily payment rate for hospice services based on one of these four categories: routine home care (RHC), continuous home care (CHC), inpatient respite care (IRC), and general inpatient care (GIP).
Possible factors that could influence the levels of hospice care and the corresponding payment rates may include:
- The minority composition of the county
- The level of care provided
- The type of care needed
- The location of care
- The length of care
- Local differences in area wage levels
Furthermore, these payment rates may be subject to annual adjustments.
Coinsurance and Out-of-Pocket Costs
While Medicare could cover a comprehensive range of hospice services, some coinsurance and out-of-pocket costs may apply. The term coinsurance denotes the share of the healthcare expenses that the patient is accountable for covering after deductibles have been fulfilled.
However, it’s worth noting that there may be a limitation on the number of days of inpatient respite care for which Medicare could provide payment, set at least 20 percent of a hospice’s total Medicare patient care days. Patients and their families need to understand these potential costs and plan accordingly.
Hospice Quality Reporting Program
The Hospice Quality Reporting Program (HQRP) could form a significant part of Medicare’s hospice coverage. It will likely be designed to gather data from hospices using the Hospice Item Set (HIS) data collection tool and Medicare hospice claims.
This collected data may also be used to assess performance on quality measures. The objective of the HQRP within Medicare’s hospice coverage will likely be to assess the hospice organization’s capacity to meet patient needs and care outcomes during their hospice stay.
The quality standards of the HQRP are formulated by the stipulations outlined in Section 3004(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. Some of the Medicare-certified hospice providers will likely be obligated to adhere to the reporting requirements of the Hospice Quality Reporting Program (HQRP).
The program currently operates under a ‘pay-for-reporting’ model, which may necessitate providers to report specific quality measures. This data could be utilized to evaluate the quality of care offered by hospices and is publicly disclosed, potentially influencing the organization’s reputation and its capacity to attract and retain staff.
Medicare Advantage Plans and Hospice Care
Though certain Medicare Advantage plans may offer supplementary health coverage, they might not extend to hospice care. Once hospice care commences, Original Medicare will likely cover the services associated with the terminal illness.
If you’re enrolled in a Medicare Advantage Plan and seeking to initiate hospice care, it may be necessary to request assistance from your plan in locating a Medicare-approved hospice provider within your vicinity.
The expenses related to hospice care within a Medicare Advantage plan could vary based on the particular plan and its regulations concerning such care. Once the hospice benefit has been initiated, Original Medicare could cover all necessary expenses related to terminal illness. This may include medical care and support services to manage symptoms and provide emotional and spiritual support.
Duration of Medicare Hospice Coverage
Another potential advantage of Medicare’s hospice coverage could be its lack of a specific time limit. Medicare will likely allow a patient to receive hospice care for an initial duration of up to two 90-day benefit periods, which may be subject to certification as terminally ill with a life expectancy of 6 months or less.
Following the initial coverage period, hospice care under Medicare may be extended through an unlimited series of 60-day benefit periods.
This possible extension of coverage may require the hospice medical director or another hospice doctor to recertify the patient’s terminal illness through a face-to-face meeting. This could mean that Medicare covers hospice care for as long as the patient needs it, as long as they continue to meet the eligibility criteria.
Possible Exclusions from Medicare Hospice Coverage
While Medicare hospice coverage could be comprehensive, there may be some exclusions. Notably, it might not include curative treatments, room and board, or services provided by non-hospice providers.
Medicare may also not cover consultations with specialist medical providers for hospice terminal diagnosis. This may require additional financial planning for patients and their families.
Moreover, Medicare might not provide Medicare coverage for:
- routine food and nutritional supplements for hospice patients
- ambulance transportation unless arranged by the hospice
- emergency department visits or hospitalizations, as typically the hospice does not authorize or arrange them.
Choosing a Hospice Program
Selecting a hospice program could be a significant decision that warrants thorough consideration. The role of a hospice doctor may involve being part of the medical team that oversees the patient’s care in a hospice program, which could ensure their comfort and proper management of the care plan.
Moreover, within a hospice program, a hospice nurse and doctor may be available around the clock to offer assistance and care to the patient and their family.
The location of the hospice program is also important, as it could determine the preferred place for care delivery and end-of-life arrangements for the patient, which could encompass the patient’s home, hospital, inpatient facility, or nursing home settings.
Finally, the reputation and quality of a hospice program may be assessed through various criteria such as:
- Live discharge rates
- The average length of stay
- Hospice care indexes
- Performance of Hospice Quality Reporting Program (HQRP) measures
Transitioning In and Out of Hospice Care
The process of transitioning into and out of hospice care will likely be designed with the flexibility to adapt to the patient’s changing needs. Indeed, a patient could have the ability to:
- Discontinue hospice care at any time
- Maintain their Medicare coverage upon discontinuation of hospice care
- Be readmitted to hospice care at any point after their decision to discontinue it, if they meet the eligibility criteria.
As long as the patient remains eligible, they can re-enter hospice care under Medicare at any time. This flexibility may be essential, as it could allow patients to adjust their care based on their changing needs and circumstances.
Summary
Medicare could provide comprehensive coverage for hospice care, focusing on comfort and symptom management for individuals with a terminal illness. It will likely cover a range of services, including pain management, medical equipment, and counseling.
The potential hospice benefit may be extended indefinitely, provided the eligibility criteria are continually met. While there may be some exclusions and potential out-of-pocket costs, the coverage will likely be designed to ensure that patients receive the comprehensive, compassionate care they need during a challenging time.
Frequently Asked Questions
→ Does Medicare cover hospice services and what might it pay for?
Yes, Medicare will likely cover services, medications, supplies, and equipment related to life-limiting illnesses through the Medicare Hospice Benefit, but it may not cover room and board expenses.
→ Which two conditions must be present for a patient to enroll in hospice?
To enroll in hospice, a patient must have a prognosis of six months or less due to a life-limiting condition and a history of frequent hospitalizations in the past six months. The patient’s declining functional status, which could be determined by factors such as a Palliative Performance Scale (PPS) rating, may also be taken into consideration.
→ What might not be included in hospice care?
Hospice care might not include treatments for curative or life-prolonging conditions, nor may it cover medications used for non-palliative reasons such as cancer treatment, organ transplants, and fertility treatments.
→ Who is eligible for hospice care?
Hospice care may be typically for patients with a life expectancy of six months or less, frequent hospitalizations, and progressive weight loss, weakness, and fatigue. It’s important to meet these criteria to be eligible for hospice care.
→ What does hospice do?
Hospiscare could provide specialized care that focuses on physical comfort, and emotional, social, and spiritual support for individuals nearing the end of life. This may include a team of doctors, nurses, social workers, and home health aides who prioritize the patient’s comfort and dignity.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.