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Medicare Hospice Benefits

Related Material:
The official government Medicare Hospice publication.

Hospice care
Hospice is a program of care and support for people who are terminally ill. Here are some important facts about hospice:

  • Hospice helps people who are terminally ill live comfortably.
  • Hospice isnít only for people with cancer.
  • The focus is on comfort, not on curing an illness.
  • A specially trained team of professionals and caregivers provide care for the ďwhole person,Ē including his or her physical, emotional, social, and spiritual needs.
  • Services may include physical care, counseling, drugs, equipment, and supplies for the terminal illness and related condition(s).
  • Care is generally provided in the home.
  • Family caregivers can get support.

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

  • Youíre eligible for Medicare Part A (Hospital Insurance).
  • Your doctor and the hospice medical director certify that youíre terminally ill 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 arenít related to your terminal illness.)
  • You get care from a Medicare-approved hospice program.

How hospice works
Your doctor and the hospice team will work with you and your family to set up a plan of care that meets your needs. Your plan of care includes hospice services that Medicare covers. For more specific information on a hospice plan of care, call your area hospice organization (see pages 12 and 14Ė15).

If you qualify for hospice care, youíll have a specially trained team and support staff available to help you and your family cope with your illness.

You and your family members are the most important part of the team. Other people on the team may include:

  • Doctors
  • Nurses or nurse practitioners
  • Counselors
  • Social workers
  • Physical and occupational therapists
  • Speech-language pathologists
  • Hospice aides
  • Homemakers
  • Volunteers

In addition, a hospice nurse and doctor are on-call 24 hours a day, 7 days a week to give you and your family support and care when you need it.

A hospice doctor is part of your medical team. Your regular doctor or a nurse practitioner can also be part of this team as the attending medical professional to supervise your care. However, only your regular doctor (not a nurse practitioner that youíve chosen to serve as your attending medical professional) and the hospice medical director can certify that youíre terminally ill and have 6 months or less to live.

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 covers
You can get a one-time only hospice consultation with a hospice medical director or hospice doctor to discuss your care options, pain, and management of your symptoms. You can get this one-time consultation if you decide not to get hospice care.

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 arenít related to your terminal illness, like care for an injury.

Medicare covers these hospice services when theyíre needed to care for your terminal illness and related condition(s):

  • Doctor services
  • Nursing care
  • Medical equipment (like wheelchairs or walkers)
  • Medical supplies (like bandages and catheters)
  • Drugs for symptom control or pain relief (may need to pay a small copayment)
  • 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 inpatient care (for pain and symptom management)
  • Short-term respite care (may need to pay a small copayment)
  • Any other Medicare-covered services needed to manage your pain and other symptoms related to your terminal illness, as recommended by your hospice team

Respite care
If your usual caregiver (like a family member) needs a rest, you can get inpatient respite care in a Medicare-approved facility (like a hospice inpatient facility, hospital, or nursing home). Your hospice provider will arrange this for you. You can stay up to 5 days each time you get respite care. You can get respite care more than once, but it can only be provided on an occasional basis.

What Medicare wonít cover
When you choose hospice care, youíve decided that you no longer want care to cure your terminal illness and/or your doctor has determined that efforts to cure your illness arenít working. Medicare wonít cover any of these once you choose hospice care:

  • Treatment intended to cure your terminal illness
    Talk with your doctor if youíre 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 drugs to cure your illness (rather than for symptom control or pain relief)
  • Care from any hospice provider that wasnít 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 canít 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 youíve chosen him or her to be the attending medical professional who helps supervise your hospice care.
  • Room and board
    Medicare doesnít cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. 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. You may have to pay a small copayment for the respite stay.
  • Care in an emergency room, inpatient facility care, or ambulance transportation, unless itís 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.

What you pay for hospice care
Medicare pays the hospice provider for your hospice care. Thereís no deductible. Youíll pay:

  • No more than $5 for each prescription drug and other similar products for pain relief and symptom control.
  • 5% of the Medicare-approved amount for inpatient respite care. For example, if Medicare pays $100 per day for inpatient respite care, youíll pay $5 per day. The amount you pay for respite care can change each year.


Hospice care if youíre in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan
All Medicare-covered services you get while in hospice care are covered under Original Medicare, even if youíre in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan. That includes any Medicare-covered services for conditions unrelated to your terminal illness or provided by your attending doctor. A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Medicare Part B benefits. However, if your plan covers extra services not covered by Original Medicare (like dental and vision benefits), your plan will continue to cover these extra services.

Care for a condition other than your terminal illness
You should continue to use Original Medicare to get care for any health care needs that arenít related to your terminal illness. You may be able to get this care from the hospice team doctor or your own doctor. The hospice team determines whether any other medical care you need is or isnít related to your terminal illness so it wonít affect your care under the hospice benefit.

You must pay the deductible and coinsurance amounts for all Medicare-covered services. You must also continue to pay Medicare premiums, if necessary
.
For more information about Original Medicare, Medicare Advantage Plans, and other Medicare health plans, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Information about Medicare Supplement Insurance (Medigap) policies
If you have Original Medicare, you might have a Medigap policy. Your Medigap policy covers your hospice costs for drugs and respite care and still helps cover health care costs for problems that arenít related to your terminal illness. Call your Medigap plan for more information.

To get more information about Medigap policies, visit
Medicare.gov. You can also call 1-800-MEDICARE.

How long you can get hospice care
Hospice care is intended for people with 6 months or less to live if the disease runs its normal course. If you live longer than 6 months, you can still get hospice care, as long as the hospice medical director or other hospice doctor recertifies that youíre terminally ill.

Important: Hospice care is given in benefit periods. You can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period, the hospice medical director or other hospice doctor must recertify that youíre terminally ill, so you can continue to get hospice care. A benefit period starts the day you begin to get hospice care and it ends when your 90-day or 60 day period ends.

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, youíll get the type of Medicare coverage you had before you chose a hospice program (like treatment to cure the terminal illness). If youíre eligible, you can go back to hospice care at any time.

Example: Mrs. Jones has terminal cancer and got hospice care for two 90-day benefit periods. Her cancer went into remission. At the start of her 60-day period, Mrs. Jones and her doctor decided that, due to her remission, she wouldnít need to return to hospice care at that time. Mrs. Jonesí doctor told her that if she becomes eligible for hospice services in the future, she may be recertified and can return to hospice care.

Your Medicare rights
As a person with Medicare, you have certain guaranteed rights. If your hospice program or doctor believes that youíre no longer eligible for hospice care because your condition has improved and you donít 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 donít 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.

For more information about your Medicare rights, visit
Medicare.gov/appeals or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have a complaint about the hospice thatís providing your care, contact your State Survey Agency. To get the phone number of your State Survey Agency or learn more about how to file a complaint, visit Medicare.gov, or call 1-800-MEDICARE.

Changing your hospice provider
You have the right to change providers only once during each benefit period. You can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods.

Finding a hospice program
To find a hospice program, talk to your doctor, or call your state hospice organization. See pages 14Ė15 for the phone number in your area. The hospice program you choose must be Medicare-approved to get Medicare payment. To find out if a certain hospice program is Medicare-approved, ask your doctor, the hospice program, your state hospice organization, or your state health department.

For more information

  1. Call National Hospice Associations, or visit their Web sites.
    National Hospice & Palliative Care Organization (NHPCO) nhpco.org
    1731 King Street
    Suite 100
    Alexandria, Virginia 22314
    1-800-646-6460

    Hospice Association of America
    nahc.org/haa
    228 7th Street, SE
    Washington, DC 20003
    1-202-546-4759
     
  2. Visit Medicare.gov.
     
  3. Call 1-800-MEDICARE (1-800-633-4227)
    TTY users should call 1-877-486-2048
     

Note: At the time of printing, these phone numbers and websites were correct. This information sometimes changes. To get the most updated phone numbers and websites, visit Medicare.gov/contacts or call 1-800-MEDICARE.

Portions excerpted from the Medicare Hospice Benefit a publication of: U.S. Department of Health and Human Services, Health Care Financing Administration.
 

Internet Link

The official government Medicare Hospice publication
 

Medicare Rights Center is a national, not-for-profit, non-governmental organization that helps ensure older adults and people with disabilities get good affordable health care.
 

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