THE MEDICARE HOSPICE BENEFIT
What is the difference between the regular Medicare home health benefit and hospice?
How does the Medicare hospice benefit coordinate with Medicaid coverage?
What is the difference between "palliative" care and "curative" care?
For other information, follow one of the links below or scroll down the page.
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QUICK SCREEN FOR HOSPICE COVERAGE |
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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:
The patient is terminally ill and has elected
Medicare hospice coverage. Patients are entitled to two 90-day
election periods, followed by an unlimited number of 60-day
periods.
The attending physician and the medical
director or physician member of the hospice interdisciplinary
team must have certified in writing at the beginning of the
first 90-day period that the patient was terminally ill. For all
subsequent election periods, only one of these physicians need
certify that the patient is terminally ill.
The patient or his or her representative has
signed and filed a hospice election form with the hospice of
choice.
The hospice provider is Medicare-certified.
The services for which Medicare coverage has
been denied were provided for the palliation and management of
the terminal illness and were included in the written plan of
care established by the attending physician or hospice physician
and the hospice interdisciplinary group.
The attending physician is always the key to obtaining Medicare coverage. Obtain a statement from the beneficiary’s physician stating that the patient is terminally ill, that the services are reasonable and necessary for the comfort and management of a terminal illness, and that the services were included in the written plan of care.
The beneficiary does not have to have cancer to qualify for the Medicare hospice benefit.
The beneficiary does not have to have a "do not resuscitate order" to qualify for the Medicare hospice benefit.
The beneficiary does not have to be homebound, and may go out as long as he or she is able to do so.
If coverage is sought for inpatient services, in a hospital or skilled nursing facility, the physician should explain why the inpatient care was reasonable and necessary and that the care could not be provided in other than an inpatient setting.
WHAT IS HOSPICE CARE?
Hospice care is compassionate end-of-life care that includes medical and supportive services intended to provide comfort to individuals who are terminally ill. Care is provided by a team.
Often referred to as "palliative care," hospice care aims to manage the patient’s illness and pain, but does not treat the underlying terminal illness.
Hospice care may include spiritual and emotional services for the patient, and respite care for the family.
Hospice care is provided by a team of appropriate professionals.
Many hospitals and skilled nursing facilities have hospice units, but most hospice care is provided at home.
Hospice Care Goals include ensuring that the patient will:
Be as comfortable and pain-free as possible.
Be independent for as long as possible.
Receive care from family and friends.
Receive support through the stages of dying.
Die with dignity.
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:
Physician services.
Nursing care.
Physical therapy, occupational therapy, and speech-language pathology services.
Medical social services.
Home health aide services.
Homemaker 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.
WHEN WILL MEDICARE COVER HOSPICE CARE?
A physician must certify that the beneficiary is terminally ill. This means that in the physician’s 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 beneficiary’s attending physician and the hospice physician must certify the beneficiary for the initial period. For subsequent periods either physician can recertify the beneficiary.
After having been certified by a physician, the beneficiary may elect the hospice benefit for two 90 day periods and an unlimited number of subsequent 60 day periods.
The care must be provided pursuant to a specific hospice plan of care signed by the attending physician.
The care must be provided by, or under
arrangements with, a Medicare certified hospice.
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.
Routine home care: Ninety-three percent of hospice care is provided at the routine home care level. Routine home care is provided where a person resides. This might be a home, a skilled nursing facility, or an assisted living facility. It is the level of care provided when the person is not in crisis. Care provided is dictated by the hospice plan of care, which is developed by the hospice team in partnership with the beneficiary’s attending physician. It will include, but is not limited to, scheduled visits from nurses, aides, and social workers, payment for palliative medications related to the terminal illness, and coverage of durable medical equipment, such as hospital beds and wheelchairs. It also includes 24 hour access to "on-call" hospice registered nurses. It does not include room and board while a beneficiary resides in a skilled nursing facility. While on routine home care, beneficiaries may be charged a five percent coinsurance for each drug furnished, but the coinsurance may not exceed five dollars per medication.
Continuous home care: Occurs where a person resides when there is a medical crisis. During such periods, the hospice team can provide up to around-the-clock care. During continuous home care, hospices bill Medicare per hour rather than per day. Coinsurance responsibility for the beneficiary is the same as routine home care.
General inpatient care: Occurs in an inpatient facility. If care cannot be managed where the patient resides, the patient will be moved to an inpatient facility until the patient’s condition is stabilized. This level of care does include coverage of room and board. Beneficiary is not responsible for any coinsurance while he or she is at a general inpatient level of care.
Inpatient respite care: Is provided in an inpatient facility. Because it is acknowledged that caring for a dying person can be difficult, this level of care is available to give the caregiver a rest. It is available for periods of up to five consecutive days. This level of care does include room and board costs. Hospices, however, may charge beneficiaries five percent of Medicare’s respite care per diem (about $135 per day in 2007).
WHAT ARE SOME OF THE DIFFERENCES BETWEEN THE MEDICARE HOSPICE BENEFIT AND THE REGULAR MEDICARE BENEFIT?
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 | 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 |
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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 |
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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). |
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HOW LONG DOES HOSPICE COVERAGE LAST?
Hospice coverage is not time limited. Initially the beneficiary must be certified as hospice eligible for a ninety day period. When this period is exhausted, the beneficiary must be certified for a second ninety day period, there are then an unlimited number of sixty day certification periods.
Beneficiaries who elect hospice coverage give up their right to regular Medicare benefits for services related to their terminal illness during the hospice election period.
Hospice beneficiaries may revoke the benefit. Upon doing this, they are immediately eligible for their traditional Medicare benefits.
After revocation, the beneficiary may re-elect the hospice benefit at any time. Upon re-election, the beneficiary begins the next certification period.
Within a certification period, the beneficiary may change his or her designated hospice program one time without the need for revocation.
MEDICAID-COVERED HOSPICE SERVICES
Medicaid-covered hospice services. Hospice is an optional benefit for state Medicaid programs. Individuals who live in states that choose to provide a Medicaid hospice benefit may be able to obtain payment for hospice services even if coverage is not available under Medicare. (For example, if the individual does not have Medicare Part A.)
Services for hospice care under Medicaid must be provided by a public agency or private organization that is primarily engaged in providing care to terminally ill individuals, that meets the Medicare conditions of participation for hospices, and that has a valid provider agreement. The Centers for Medicare & Medicaid Services (CMS) has taken the position that states may provide a more limited benefit under Medicaid than is available under Medicare. At a minimum, however, Medicaid hospice coverage must be available for at least 210 days. The services to be covered under Medicaid are essentially those described above for Medicare-covered hospice. Certification periods may be subdivided into two or more periods.
Election of benefit. An individual electing
the Medicaid hospice benefit must be eligible for Medicaid in
the state in which she resides. Limitations on co-payments and
deductibles would be reflected in the state’s Medicaid plan in
accordance with Medicaid law.
COORDINATION OF SERVICES AND DUALLY ELIGIBLE BENEFICIARIES
Medicare Hospice and "Regular" Medicaid Benefits. Hospice care is available for individuals who live in Medicaid-reimbursed nursing facilities. Under these circumstances, Medicare Part A will pay the hospice program for the palliative care. The state Medicaid agency will pay the hospice program a daily rate for the hospice patient’s room and board, the hospice program must then reimburse the nursing facility for the room and board. Room and board services include the performance of personal care services, assistance in the activities of daily living, socializing activities, administration of medications, maintaining the cleanliness of the resident’s room, and supervising and assisting in the use of durable medical equipment and prescribed therapies.
Medicare Hospice and Medicaid Waiver
Programs. CMS recently clarified that people who are qualified
for Medicare and for a state’s Medicaid home and community-based
"waiver program," may utilize the benefits from both
simultaneously. The Medicare-certified hospice provider is
responsible for coordinating the hospice patient’s plan of care
and for the professional management of the hospice patient’s
care in any setting. The hospice provider is to initiate the
coordination of services with the Medicaid waiver program’s case
manager and is to assure that the hospice patient receives all
of the care and services necessary to support and maintain the
patient in her home environment. In turn, the home and
community-based waiver program’s case manager is responsible for
adjusting the waiver services so that there is no duplication of
services.
PHYSICIAN EDUCATION ABOUT THE HOSPICE BENEFIT
Physicians are often confused about how Medicare interprets its terminal illness requirement. They often delay certifying patients for hospice care or refuse to re-certify patients who do not die within the first six months of the initial certification, even when the patient’s conditions and clinical prognosis remain unchanged. It is often difficult for beneficiaries and their advocates to convince physicians that hospice certification may well remain appropriate, that the beneficiary need not have died within six months for the hospice certification to have been legitimate, and that recertification should not result in a fraud claim.
Medicare published an article in several professional magazines to provide physicians with information about the hospice benefit and to encourage them to consider ordering hospice services for their patients earlier in the course of a terminal illness. Medicare also sent a letter to physician associations to let physicians know that the Agency understands that making a prognosis about life expectancy and end of life is not an exact science and that the end-point of a terminal illness cannot be precisely predicted.
Copyright © 2008 Center for Medicare Advocacy, Inc.