Medicare Hospice Benefits
Hospice care is a special way of caring for a patient whose disease cannot be cured. It is available as a
benefit under Medicare Hospital Insurance (Part A). Medicare beneficiaries who choose hospice care receive non-curative medical and support services for their terminal illness.
To be eligible, they must be certified by a physician to be terminally ill with a life expectancy of six months or less. While they no longer receive treatment toward a cure, they require close medical and supportive care which a
hospice can provide. Hospice care under Medicare includes both home care and inpatient care, when needed, and a variety of services not otherwise covered by Medicare. The focus is on care, not cure. Emphasis is on helping the person to make the most of each hour and each day of remaining life by providing comfort and relief from pain.
This document explains the special rules that govern Medicare coverage
of, and payment for, hospice care.
What is hospice care?
Under Medicare, hospice is primarily a program of care delivered in a personís home by a Medicare - approved hospice. Reasonable and necessary medical and support services for the management of a terminal illness are furnished under a plan-of-care established by the beneficiaryís attending physician and the hospice team.
- physiciansí services,
- nursing care (intermittent with 24-hour on call),
- medical appliances and supplies related to the terminal
- outpatient drugs for symptom management and pain relief,
- short-term acute inpatient care, including respite care,
- home health aide and homemaker services,
- physical therapy, occupational therapy and speech/language pathology services,
- medical social services, and
- counseling, including dietary and spiritual counseling.
Who is eligible?
Hospice care is available under Medicare only if:
- The patient is eligible for Medicare Hospital Insurance (Part A);
- The patientís doctor and
the hospice medical director certify that the patient is terminally ill with six months or less to live if the disease runs its expected course.
- The patient signs a statement choosing hospice care instead of standard Medicare benefits for the terminal illness;
- The patient receives care from a Medicare-approved
Who can provide hospice care?
Hospice care can be provided by an agency or organization that is primarily engaged in furnishing services to terminally ill individuals and their families. To receive Medicare payment, the agency or organization must be approved by Medicare to provide hospice
Approval for hospice is required even if the agency or organization is already approved by Medicare to provide other kinds of health services. Patients can find out whether a hospice program is approved by Medicare by asking their physician or checking with the agency or organization offering the program. This information also is available from local Social Security offices.
Hospice uses a team approach that includes the patient and family, nurses, social workers, physicians, clergy and volunteers, all working together to plan and coordinate care. Family or friends (serving as primary caregivers) in the home can call for the help of a hospice team member 24 hours a day, 7 days a week. The team member will come to the patientís home whenever needed and appropriate. The hospice team can arrange
for a transfer to another setting when necessary.
How long can hospice care continue?
Special benefit periods apply to hospice care. A Medicare beneficiary may elect to receive hospice care for two 90-day periods, followed by an unlimited number of 60-day periods. The benefits periods may be used consecutively or
at intervals. Regardless of whether they are used one right after the other or at different times, the patient must be certified as terminally ill at the beginning of each period.
A patient who chooses hospice care may change hospice programs once each benefit period. A patient also has the right to cancel hospice care at any time and return to standard Medicare coverage, then later reelect the hospice
benefit in the next benefit period. If a patient cancels during one of the first three benefit periods, any days left in that period are lost.
How is payment made?
Medicare pays the hospice directly at specified rates depending on the type of care given each day. The patient is responsible only for:
- Drugs or
biologicals: The hospice can charge 5 percent of the reasonable cost, up to a maximum of $5, for each prescription for outpatient drugs or biologicals for pain relief and symptom management related to the terminal illness.
- Inpatient Respite care: The hospice may periodically arrange for inpatient care for the patient to give temporary relief to the person who regularly provides care in the home.
Respite care is limited each time to a stay of no more then 5 days. The charge (currently 5%), which is subject to change each year, varies slightly depending on the geographic area of the country.
Are other Medicare benefits available?
When Medicare beneficiaries choose hospice care, they give up the right to standard Medicare benefits only for treatment of the terminal illness. If the patient,
who must have Part A in order to use the Medicare hospice benefit, also has Medicare Part B, he or she can use all appropriate Medicare Part A and Part B benefits for the treatment of health problems unrelated to the terminal illness. When standard benefits are used, the patient is responsible for Medicareís deductible and coinsurance amounts.
What is not covered?
All services required for treatment
of the terminal illness must be provided by or through the hospice. When a Medicare beneficiary chooses hospice care, Medicare will not pay for:
- Treatment for the terminal illness which is not for symptom management and pain control;
- Care given by another healthcare provider that was not arranged for by the
patientís hospice; and
- Care from another provider which duplicates care the hospice is required to provide.
To determine whether a Medicare-approved hospice program is available in your area, contact the nearest Social Security Administration office, your state or local health department, your state hospice
organization, or call the National Hospice Organization Hospice HelpLine (800) 658-8898.
Portions excerpted from the Medicare Hospice Benefit a publication of: U.S. Department of Health and Human Services, Health Care Financing Administration.