Since 1983, the Medicare hospice benefit has enabled Medicare beneficiaries and their families to receive end-of life care that provides comfort, compassion, and dignity. The hospice benefit covers a team-oriented approach to expert medical care, pain management, and emotional and spiritual support. The Medicare benefit can make the difference between individuals receiving or not receiving palliative care.

The Medicare hospice benefit consists of two 90 day certification periods and an unlimited number of subsequent 60 day periods. Eligibility for Medicare hospice coverage hinges on the requirement that the beneficiary have a hospice certification. For the beneficiary’s first 90 day certification period, the hospice certification must be obtained from both the beneficiary’s attending physician and the hospice medical director or the physician member of the hospice interdisciplinary group. For subsequent periods, the only requirement is certification by one of the aforementioned physicians.

According to the Medicare statute, the content of the certification must specify that the individual’s prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course. Other than this certification, Medicare requires nothing else for a determination of hospice eligibility. Contrary to popular belief, the individual does not need to have a "do not resuscitate" order to qualify for the Medicare hospice benefit. Further, the six month life expectancy certification is to be based on the physician’s best clinical judgment. The physician should not be penalized if the individual lives beyond a good faith six month clinical prognosis. Indeed, the hospice benefit is not limited to six months; if the individual survives beyond six months the benefit can continue.

The Congress and the Centers for Medicare & Medicaid Services (CMS) seem to recognize the importance of hospice care and have made changes to encourage use of the Medicare benefit. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003; Public Law 108-173 (12/8/2003) continues the effort to enhance the value and use of the Medicare benefit. Unfortunately, the Medicare hospice benefit and the important services it covers are underutilized. Advocates should be aware of the hospice benefit criteria and covered services in order to help their clients obtain quality end-of-life care.

The hospice provisions of the new Medicare Act of 2003 include the following:

• Coverage of Hospice Consultation Services

Effective January 1, 2004, if a Medicare beneficiary is terminally ill and has not yet elected the hospice benefit, Medicare will pay for a consultation visit with the hospice medical director or physicians who are employees of a hospice program. During this visit, the physician may: evaluate the individual’s need for pain and symptom management; counsel the individual with respect to end-of-life issues and care options; and advise the individual regarding advanced care planning. Hospices will receive payment for this service that is equal to the amount established for an office or other outpatient visit for evaluation and management associated with presenting problems of moderate severity under the established Medicare physician fee schedule other than the portion of the amount attributable to the practice expense component. The physician, if not a volunteer, will be paid by the hospice.

• Nurse Practitioners Services

Effective October 1, 2004, in addition to coverage for the physician who certifies that a beneficiary is terminally ill, Medicare payments will be made for the services of a nurse practitioner chosen by the beneficiary instead of a physician as having the most significant role in the determination and delivery of the beneficiary’s medical care. The nurse will not be authorized to certify the beneficiary as terminally ill, but will be able to review hospice plans of care.

• Provision of Core Hospice Services

Effective December 8, 2003, a hospice may, under extraordinary circumstances, enter into arrangements with another hospice to provide core hospice services to Medicare beneficiaries. These extraordinary circumstances include: unanticipated high patient loads, staffing shortages due to illness or other events, or temporary travel of a patient outside a hospice program’s service area. The hospice program making these arrangements will bill and be paid for the hospice care.

• Rural Hospice Demonstration Project

Three hospice programs will be selected to take part in a demonstration project, which will last no longer than five years. The chosen hospices will provide hospice care to Medicare beneficiaries who live in rural areas and who do not have able caregivers. The hospice care will be provided in facilities that have 20 or fewer beds and offer the full range of services usually provided by hospice programs. Payments to the demonstration hospice programs will be the same as payments made to non-demonstration hospice programs.

© Copyright, Center for Medicare Advocacy, Inc. 09/10/2013