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Medicare Hospice Benefit
Who is eligible?
What services are generally included in the hospice plan of care?
What services must be pre-authorized before inclusion in the hospice plan of care?
What services are generally not considered part of the hospice plan of care?
How long can I receive hospice care?
What costs are covered and what do I pay?
Who is eligible? You are eligible for the Medicare Hospice Benefit if:
- you are entitled to receive Medicare Part A.
- you sign a statement electing hospice care and the Hospice Benefit, rather than curative treatment and standard Medicare benefits for your terminal illness (Hospice will provide you with the election statement).
- your doctor and the hospice medical director certify that you have a terminal illness with a life expectancy of approximately six months or less, should the illness run its expected course.
It is important to note that if a beneficiary of Medicare Hospice Benefit receives services related to his or her terminal illness that are NOT included in the plan of care, regardless of whether the services are palliative or curative in nature, NEITHER MEDICARE NOR THE HOSPICE IS FINANCIALLY LIABLE FOR THE SERVICES. Ultimately, the beneficiary retains the financial responsibility for care not approved by the Hospice.
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What services are generally included in the hospice plan of care? As long as they relate to your terminal diagnosis, the following services are generally included in the Hospice Plan of Care:
- Physician services for the medical direction of your care. These services may be provided by your community doctor or by a Hospice physician
- Regular home care visits by Hospice registered nurses (RNs) to monitor your condition and provide appropriate care
- Social work support services
- Bereavement support during the grieving process
- Certified Nursing Assistant (CNA) visits to provide personal care
- Chaplain services for you and/or your family
- Volunteer support services
- Dietician
- Intermittent respite care at an approved facility
- 24-hour on-call nurse
- Palliative medicines for comfort or symptom relief
- Tube (enteral) feedings, if they are the primary source of nutrition
- Physical, occupational, speech, and enterostomal therapy (wound and ostomy care), as needed
- Supplies related to your terminal illness; for example, wound care supplies
- Durable medical equipment, such as a hospital bed, wheelchair, bedside commode.
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What services must be pre-authorized before inclusion in the hospice plan of care? Services that require pre-approval are those that may not always seem to be directly related to the Plan of Care. They require careful consideration, and include:
- Inpatient care
- Hospitalization
- Emergency room visits
- Physician consultation visits other than those by the patient’s attending physician
- Any surgical procedures
- Radiotherapy and chemotherapy for symptom management
- Blood platelet transfusions
- Infusion therapy
- Placement or revision of bilarary stents or ureteral stents
- Placement of feeding type tubes (gastrostomy or jejunostomy)
- Procedures to view the intestinal tract (endoscopy, colonoscopy, or sigmoidoscopy)
- Ambulance transportation
- Procedures to remove excess fluid from the abdomen or lungs
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What services are generally not considered part of the hospice plan of care? The Medicare Hospice Benefit is designed to provide palliative rather than curative or life-prolonging services. Medicare also requires that services provided under the Medicare Hospice Benefit be delivered either directly by the hospice in which you are enrolled, or by providers with whom the hospice has a written agreement for the provision of services. Consequently, the following services are generally not included in the Hospice Plan of Care:
- Hospitalization in hospitals that are not covered by Hospice or hospitalization that is not related to the patient’s terminal diagnosis
- Emergency room visits at hospitals not covered by Hospice
- Any service rendered at a facility that is not covered by Hospice
- Chemotherapy and radiotherapy intended for cure or life prolongation
- Antiretroviral therapy intended for cure or life prolongation
- Amyotrophic lateral sclerosis (ALS) drugs intended for life prolongation
- Total parenteral nutrition (nutrition delivered through IVs)
- Dialysis treatment
- Any experimental treatment
- Use of respirators
- ICU
- Custodial care service
- Hormones and drugs that stimulate cell growth
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How long can I receive hospice care? The Medicare Hospice Benefit is divided into benefit periods. The first two periods consist of 90 days of care followed by unlimited periods of 60 days each. The Hospice team will evaluate your continued stay based on the same three criteria used at the start of your care (see “Who is Eligible?”). You have the right to change hospice providers once during each benefit period and cancel hospice services at any time. You also have the right to resume standard Medicare coverage, and you may re-elect the Medicare Hospice Benefit again, provided you meet the criteria.
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What costs are covered and what do I pay? The Medicare Hospice Benefit pays for services, medications, and treatments that are required to manage your terminal illness. However, to be covered, those services, medications, and treatments must be approved by hospice as part of your individual plan of care. You may be responsible for a five percent co-payment for drugs and a five percent co-payment for inpatient respite care. Only services and care related to the terminal illness are covered by the Medicare Benefit. Coverage for services unrelated to the terminal illness remains unchanged.
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