Wednesday, November 23, 2022

Is Hospice Covered By Medicare Part A

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Does Medicare Cover Hospice Care

Understanding Medicare Part A

Q: Does Medicare cover hospice care?

A: Medicare covers almost all aspects of hospice care with little expense to patients or families, as long as a Medicare-approved hospice program is used. . More than 1.5 million Medicare beneficiaries received hospice care in 2018, with services provided by more than 4,600 hospice programs nationwide.

Hospice programs provide care and support for people who are terminally ill. Their focus is on comfort, or palliative care, not on curing an illness. When a Medicare beneficiary enters hospice, the hospice benefits are typically provided via Original Medicare, even if the beneficiary had previously been enrolled in Medicare Advantage.

If a Medicare Advantage enrollee who is in hospice care needs treatment for something that isnt part of the terminal illness or related conditions, they can choose to use Original Medicare or their Medicare Advantage coverage.

To qualify for hospice benefits, a patient must be eligible for Medicare Part A, and a doctor must certify that the patient is terminally ill and has six months or less to live. Medicare-approved programs usually provide care in your home or other facility where you live, such as a nursing home or, in some cases, hospitals.

Theres no deductible for hospice care, and copays for covered medications for pain or symptom management wont exceed $5 .

Hospice care continues as long as the hospice medical director or doctor recertifies that youre terminally ill.

When Does Medicare Cover Hospice Care: Quick Screen For Hospice Coverage

Medicare claims for hospice care are suitable for coverage, and appeal if they are denied, if they meet the following criteria:

  • A hospice physician must certify that the beneficiary is terminally ill. This means that in the physicians judgment the individual has 6 months or less to live if the illness runs its normal course.
  • The beneficiary or his/her representative must elect the Medicare hospice benefit by signing and filing a hospice benefit election form with the hospice of choice.
  • The beneficiarys attending physician and the hospice physician must certify the beneficiary for the initial period. For subsequent periods the hospice physician recertifies the beneficiary.
  • After having been certified by a hospice physician, the beneficiary may elect the hospice benefit for two 90 day periods and an unlimited number of subsequent 60 day periods.
  • Before the start of each 60-day period, the beneficiary must have a face-to-face encounter with a hospice physician or nurse practitioner to determine continued eligibility.
  • All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician , the patient or representative, and the primary caregiver, in accordance with the patients needs if any of them so desire.
  • The care must be provided by, or under arrangements with, a Medicare certified hospice.

What Do Medicares Hospice Benefits Cover

If you qualify and choose to receive hospice care, the benefits should cover everything you need related to your terminal illness with very little cost to you. Your hospice team creates a care plan that may include the following covered services:

  • Doctor services and nursing care
  • Drugs to help control your pain
  • Health aide and homemaker services
  • Medical equipment and supplies
  • Physical therapy, occupational therapy and speech and language pathology services
  • Short-term inpatient care in a Medicare-approved facility, such as a hospice facility, hospital or skilled nursing facility, for pain and symptom management. This also covers inpatient respite care so your caregiver can get a break. You can get occasional respite care for up to five days each time.
  • Social work services and dietary counseling
  • Spiritual and grief counseling for you and your family
  • Support for your caregiver
  • Other Medicare-covered services that your hospice team recommends to manage your terminal illness and related conditions

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Medicare & Inpatient Hospice

Hospice care is a special kind of care that provides comfort, support, and dignity at the end of life, typically when you or your loved ones life expectancy is six months or less. This care addresses your physical, emotional, social, and spiritual needs, and enables you to spend time focusing on what matters most to you.

What Does Medicare Cover For Hospice Care

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Medicare provides a one-time consultation with a hospice medical director or doctor. This lets you discuss your care options and methods available for managing pain and symptoms. This consultation is covered, even if you decide you don’t want hospice care.

Once your benefit starts, it covers any care for your terminal illness or any related conditions. This includes physical care, counseling, drugs, equipment and supplies. Care is typically provided where you currently live, which lets you stay with your family in the comfort of your home. Inpatient care is covered if its needed, and your provider will make the arrangements.

The benefit doesnt allow for 24-hour care in your home caregiving is provided by your family when professionals arent there. However, a hospice nurse and doctor are on call around the clock to provide support when needed. The benefit also covers respite care if your caregiver needs a rest.

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How Much Does Hospice Care Cost With Medicare

How much hospice care costs depends on the type of illness and how early patients enter hospice. In 2018, the Society of Actuaries estimated that hospice patients with cancer received Medicare Part A and Part B benefits totaling around $44,030 during the last 6 months of their lives.

That figure includes the cost of inpatient hospital treatments, in addition to at-home hospice care.

The good news is that there are no deductibles for hospice care under Medicare.

Some prescriptions and services may have copays. Prescriptions for pain medications or symptom relief may carry a $5 copay. There may be a 5 percent copay for inpatient respite care if you are admitted to an approved facility, so your caregivers can rest.

Other than those instances, you wont have to pay for your hospice care.

Faq: How Is Hospice Care Paid For

Patients with a terminal illness do not usually have to pay for hospice care.

Hospice care costs are covered by Medicare , Medicaid , and The Veterans Health Administration

Medicare and Medicaid

  • Currently, most hospice patients have their costs covered by Medicare, through the Medicare Hospice Benefit. Learn more about the Medicare Hospice Benefit.
  • Medicaid also pays for hospice care in most states. People become eligible for Medicaid when their income and assets are low.
  • Medicaid provides benefits that are very similar to the Medicare Hospice Benefits.

Veterans Benefits

  • The Veterans Health Administration also covers hospice care. If you think you may be eligible, you can read further information for veterans benefits.
  • The Veterans Health Administration provides benefits that are very similar to the Medicare Hospice Benefits.

Health Insurance

  • Many private insurance companies provide some coverage for hospice care. Check with your insurer to determine whether hospice care is covered and under what circumstances. Among private insurers, there are variations in qualifications and covered benefits.

Individuals who do not have insurance

Whether a patient is eligible for hospice benefits may vary depending on who is covering the cost of care. Currently, most hospice care in the US is covered by the Medicare Hospice Benefit, which requires:

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What Kinds Of Care Does Hospice Include

Generally, hospice care includes services which are reasonable and necessary for the comfort and management of a terminal illness. These services may include:

  • Physician services.
  • Medical supplies, including drugs and biologicals and medical appliances.
  • Counseling, including dietary counseling, counseling about care of the terminally ill patient, and bereavement counseling.
  • Short term inpatient care for respite care, pain control, and symptom management.

Is There A Copayment For Medicare Hospice Coverage

Medicare & You: Hospice

If you have Original Medicare, you pay nothing for hospice care. However, if you need a prescription for outpatient drugs for pain and symptom management, you will pay a copayment of up to $5 for each prescription.8

Also, if you need inpatient respite care you may pay 5% of the Medicare-approved amount. And if you live in a facility and choose to get hospice care, you may have to pay your room and board.9

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Pain & Symptom Management

Sometimes you or your loved one may experience severe pain and symptoms, and your healthcare provider or hospice nurse might recommend the inpatient level of hospice care. The inpatient level of hospice care is usually provided in an inpatient hospice facility such as The Samaritan Centers at Voorhees and Mount Holly.

Medicare Part A Coverage

Medicare beneficiaries pay nothing for hospice care as part of Medicare Part A coverage. Prescription medications for pain and symptom management will have a copay of only up to $5 each, unless the drugs are not covered by the hospice benefit or Part D. Inpatient respite care may cost 5% of the Medicare-approved amount.

You can receive your hospice care at a facility, but Medicare will not pay for your room and board.

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Hospice Costs With Medicare

When a patient is in hospice, they have very few costs from Medicare. They need to pay the monthly premium to have Medicare Part A and B, and they may pay up to $5 per prescription for pain and symptom management.

If the patient gets respite care at an inpatient facility, there will be coinsurance of 5% of the Medicare-approved amount. Finally, the patient is responsible for room and board if hospice is given at their home or in another facility where they live, like a nursing home.

If a patient gets care outside of hospice care thats related to the terminal illness, they will have to pay the full cost. For example, if a loved one is in hospice due to cancer and they go to the hospital for treatment related to that cancer, that treatment is not covered and the patient is responsible for the entire bill.

Differences Between The Medicare Hospice Benefit And Regular Medicare

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  • Medicare hospice coverage is limited to beneficiaries who are terminally ill.
  • Hospice coverage is for pain and symptom management and comfort, not for curative treatment of the underlying terminal illness.
  • Hospice coverage is holistic. Not only is medical care covered, but so are social work services, chaplain services, bereavement services and homemaker services.

A Comparison of Medicare Home Health Benefits and Hospice Benefits

Service
Not Covered Covered, during periods of medical crisis

¹ There are additional services that can be provided in the home, but are not included in the home health benefit. Medicare will pay for reasonable and necessary home health visits if all the following requirements are met: 1. Patient needs skilled care 2. Patient is homebound 3. Care is authorized by physician and 4. Home Health agency is Medicare-certified. .² Medicare will pay for hospice care if all the following requirements are met: 1. Prognosis that life expectancy is 6 months or less. 2. Terminal illness is certified by physician 3. Patient elects hospice benefit 4. Care is specified in the hospice plan of care and 5. Hospice program is Medicare-certified. .

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Your Costs For Hospice Care Under Medicare

Medicare Part A covers most hospice services in full, but you may have the following out-of-pocket costs:

  • A maximum of $5 per prescription for drugs used to control the symptoms and pain of your terminal illness
  • Up to 5 percent of the cost of inpatient respite care
  • Room and board if you live in a facility that is not for hospice care, such as a nursing home, but choose to receive hospice care there

Keep in mind

You are free to stop hospice care any time you want to and then resume it if thats your wish. Medicares hospice coverage continues as long as your doctor and a hospice doctor continue to certify that youre terminally ill, even if you live longer than six months.

You can use Medicare benefits to get care for health problems that arent a part of your terminal illness, paying for any of Medicares copayments and deductibles as usual. But once you choose hospice care, you cant use your Medicare benefits to cure your terminal illness.

Original Medicare will cover your hospice benefits, even if youve chosen a Medicare Advantage plan. If you already had a Medicare Advantage plan before you started hospice care, you can choose to stay in that plan if you pay the monthly premiums. The plan can cover care not related to your terminal illness.

How Long Will Medicare Pay For Hospice Care

Hospice care is for patients who have six months or less to live. However, estimating someones life expectancy is not an exact science. Therefore, the Medicare hospice benefit is broken down into two 90-day benefit periods that are followed by an unlimited number of 60-day benefit periods .

A terminally ill patient can continue receiving covered hospice care as long as their hospice physician continues to certify that they have six months or less to live. Some people retain their terminal status yet survive much longer than expected and remain under hospice care for many months or even years.

A patient must be certified as having six months left to live before the services can begin and be recertified at the start of each new benefit period. A face-to-face meeting with a hospice doctor is required prior to the start of their third benefit period to recertify their eligibility. These face-to-face recertification meetings are then required prior to each subsequent 60-day benefit period and must take place no earlier than 30 days before the new benefit period begins.

Due to the ongoing COVID-19 pandemic, keep in mind that the Centers for Medicare and Medicaid Services has temporarily eased some regulations, allowing telehealth services to be used in place of face-to-face encounters where appropriate. This includes hospice recertification visits.

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What The Medicare Hospice Benefit Covers

The Medicare hospice benefit covers all of the care related to your terminal illness and necessary to keep you comfortable, as long as you receive your care from a Medicare-approved hospice vendor. It pays for:

  • Hospice physicians and nurses.
  • Medications necessary to keep you comfortable and control or prevent your symptoms.
  • Hospice home health aides to help with bathing and bed changes.
  • Medical equipment like a wheelchair or hospital bed necessary to keep you comfortable.
  • Social workers to help you get your affairs in order and to help you and your family deal with emotional difficulties and grief.
  • Respite care needed to give your caregiver a break.
  • Speech, occupational, or physical therapy needed to keep you comfortable or teach you how to cope with the changes your body is undergoing.
  • Dietician services if necessary.
  • Grief counseling for both you and your loved ones.
  • Inpatient admission if necessary for crisis management, approved by the hospice team, and received at a hospital or hospice facility contracted with your hospice organization.
  • Anything else the hospice team feels is necessary and related to keeping you comfortable and limiting the symptoms of your terminal illness.

What Health Services Does Medicare Provide With Hospice Coverage

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Hospice care provided through Medicare is usually given in your home or a long-term care facility you live in such as a nursing home. Generally, hospice coverage should cover most of your health care needs, but if not Medicare Parts A and B will still pay for covered benefits and services for health problems unrelated to your terminal illness and accompanying conditions.

Medicare.gov provides the following list of covered items for hospice:

  • All items and services needed for pain relief and symptom management
  • Medical, nursing, and social services
  • Drugs for pain management
  • Durable medical equipment for pain relief and symptom management
  • Aide and homemaker services
  • Other covered services you need to manage your pain and other symptoms, as well as spiritual and grief counseling for you and your family

Other health care services may also be covered under your hospice plan, but it depends on the specific terminal illness and related conditions you have. These additional covered services could include things such as physical therapy services, dietary counseling, and spiritual and grief counseling for you and your family. See a more complete list from Medicare.gov here.

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What It Doesn’t Cover

The Medicare hospice benefit doesnt cover anything aimed at curing your terminal illness. For example, it might cover the cost of radiation therapy aimed at shrinking a tumor that is pressing against your spinal cord causing pain. But, it wouldnt cover radiation therapy aimed at curing your disease. The key is whether the treatment is to control your symptoms so you can be comfortable , or whether the treatment is an attempt to cure your terminal illness .

The Medicare hospice benefit also doesnt cover the cost of room and board with the exception of short-term inpatient stays arranged by the hospice team or respite care of up to five days at a time. This isnt usually a problem if youre in your own home, which is where hospice care is generally provided.

But if you are in a nursing home, assisted living facility, board and care home, or living at a hospice facility, youll be responsible for covering your room and board costs. If its clear that you need to live in a nursing home, assisted living, or hospice house but cant afford room and board, some hospice organizations will use charitable donations to assist you with those costs. This is usually done on a case-by-case basis, so if you predict this may be an issue, ask about it as youre choosing which hospice organization to use. Depending on your financial situation, you may also find that Medicaid might cover the room and board costs associated with a nursing home.

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