THE MEDICARE HOSPICE BENEFIT

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QUICK SCREEN FOR HOSPICE COVERAGE

WHAT IS HOSPICE CARE?

WHAT KIND OF CARE IS INCLUDED?

WHEN WILL MEDICARE COVER IT?

HOSPICE LEVELS OF CARE

HOSPICE vs. REGULAR MEDICARE

HOSPICE  vs. HOME HEALTH BENEFITS

ADVOCACY TIPS

MEDICAID-COVERED SERVICES

DUALLY ELIGIBLE BENEFICIARIES

PHYSICIAN EDUCATION

 


A QUICK SCREEN TO AID IN IDENTIFYING COVERABLE CASES

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

ADVOCACY TIPS:

WHAT IS HOSPICE CARE?

WHAT KINDS OF CARE DOES MEDICARE HOSPICE CARE INCLUDE? 

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

WHEN WILL MEDICARE COVER HOSPICE CARE?

HOSPICE LEVELS OF CARE

Generally, Medicare pays hospice agencies a daily rate for each day a beneficiary is enrolled in the hospice benefit.  This daily payment is made regardless of the amount of services provided on a given day, and even on days where no services are provided.  The daily payment rates are intended to cover costs that hospices incur in furnishing services identified in patients’ care plans.  Payments are made according to a fee schedule that has four base payment amounts for the four different categories of care.

WHAT ARE SOME OF THE DIFFERENCES BETWEEN THE MEDICARE HOSPICE BENEFIT AND THE REGULAR MEDICARE BENEFIT?

A Comparison of Medicare Home Health Benefits and Hospice Benefits
Service Medicare Home Health Benefitą Medicare Hospice Benefit˛
Skilled Nursing Covered for skilled care, if part-time or intermittent, or daily for 21 days or less. Covered for skilled and supportive care
Physician Not covered under home care, but 80% of approved charge covered under Part B Attending non-hospice affiliated physician 80% covered under part B; consulting hospice physician 100% covered
Medical Social Work Covered for patient Covered for patient and caregivers
Chaplain Services Not covered Covered
Homemaker/Home Health Aide Covered if part-time or intermittent, must provide "hands on personal care." 28-35 /wk w/SN & HHA Covered, no hourly restriction.
Volunteers For Patient & Caregivers Not included Included
Medications Related to Primary Illness Not included Covered, Possible $5.00 coinsurance per medication
Durable Medical Equipment 80% of approved amount covered 100% covered
Respite Care Not covered Covered for up to 5 consecutive days. Possible coinsurance
24-Hour On-Call Nurse Not required Included
Bereavement Care Not included Included
Inpatient Care Not covered under home care, but covered under hospital benefit Covered
Medical Supplies Medical supplies covered Medical and personal supplies covered
Dietician Not covered for individual patients Covered
Physical Therapy
Occupational Therapy
Speech-Language Pathology
Covered with some limitations on occupational therapy Covered
Services to Nursing Facility Residents Not covered Room & Board not covered
Skilled Continuous Care Not Covered Covered, during periods of medical crisis
ąThere 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. (42 CFR §409.42)

˛Medicare will pay for hospice care if all the following requirements are met: 1. Prognosis that life expectancy is 6 months or less. (42 CFR §418.3) 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. (42 CFR §418.21, 418.22, 418.24).

HOW LONG DOES HOSPICE COVERAGE LAST?

MEDICAID-COVERED HOSPICE SERVICES

COORDINATION OF SERVICES AND DUALLY ELIGIBLE BENEFICIARIES

PHYSICIAN EDUCATION ABOUT THE HOSPICE BENEFIT

Copyright © 2008 Center for Medicare Advocacy, Inc.