As a Medicare Advisor I understood that Medicare provided some measure of hospice coverage. However, my friend’s experience and the genuine gratefulness he expressed surprised and, quite unexpectedly, moved me. It also left me curious; driving me to take a fresh look, a deeper dive, to learn more about Medicare’s hospice coverage.
My friend’s experience and the genuine gratefulness he expressed surprised and, quite unexpectedly, moved me. It also left me curious; driving me to take a fresh look, a deeper dive, to learn more about Medicare’s hospice coverage.
Doing so has better equipped me to help clients more clearly understand their respective Medicare coverage. I thought some of you might find it interesting and perhaps helpful to you, or someone you care about, if I shared a few of the key elements of Medicare’s Hospice Coverage via this column.
Here are four salient points you may want to know about hospice coverage and how Medicare addresses it.
#1 What Exactly is Hospice?
Hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. Medicare’s hospice benefit is primarily home-based and covers end-of-life palliative treatment (care aimed at relief and comfort rather than a cure), including support for one’s physical, emotional, and other needs.
It is important to remember that the goal of hospice is to help an individual be as comfortable as possible, not to cure an illness.
#2 What Does Medicare’s Hospice Benefit Cover?
Services commonly covered include (but are not limited to):
- Doctor services
- Skilled nursing services
- Skilled therapy services
- Hospice aides and homemaker services
- Medical supplies
- Durable medical equipment
- Respite care
- Short-term inpatient care
- Medical social services
- Prescription drugs related to pain relief and symptom control
- Spiritual or religious counseling
- Nutrition and dietary counseling
#3 How Does Someone Elect the Hospice Benefit and How Does Hospice Care Work?
To elect hospice, a patient must:
- Be enrolled in Medicare
- Be certified to have a terminal illness (meaning a life expectancy of six months or less) by the hospice doctor and their regular doctor
- Sign a statement electing to have Medicare pay for palliative care, rather than curative care (care aimed at overcoming illness and promoting recovery)
- And receive care from a Medicare-certified hospice agency
Once someone chooses hospice care, all their hospice-related services are covered directly under Original Medicare, even if they are enrolled in a Medicare Advantage Plan (some exceptions apply). While someone covered by a Medicare Advantage Plan is in the hospice program, the hospice provider bills Medicare directly and Medicare pays for the hospice services. The respective Medicare Advantage Plan continues to cover and pay for any care that is not related to the terminal condition.
Hospice also covers any prescription drugs needed for pain and symptom management for the terminal
condition. Customary Medicare prescription drug coverage (included as part of either a Medicare Advantage Plan or a stand-alone Prescription Drug Plan) continues to cover medications that are unrelated to the terminal condition.
Hospice generally takes place at home, with the hospice provider sending aides, nurses, and/or skilled therapists to the patient’s place of residence.
Hospice can sometimes take place at an inpatient facility if the hospice provider determines that is
necessary. If so, the hospice provider must be the one to make the arrangements. If the hospice
provider doesn’t make the arrangements; the beneficiary may be responsible for the full cost of the stay.
If someone is interested in Medicare’s hospice benefit, they should ask their primary health care provider whether the specific case meets the eligibility criteria for Medicare-covered hospice care. If so, the doctor can contact a Medicare-certified hospice agency on the patient’s behalf. There may be several agencies in an area; if one is unable to help, contact another.
The hospice agency’s medical director (and the regular doctor if applicable) will certify eligibility for hospice care. The patient must sign a statement electing hospice care and waiving curative treatments for the terminal illness. The patient’s hospice team consults the patient, the primary care provider, and any designated caregiver if desired, to develop a plan of care. The care team may include a hospice doctor, a registered nurse, social worker, and a counselor.
Medicare covers hospice care for two 90-day benefit periods, followed by an unlimited number of
60-day benefit periods, with doctor approval.
#4 How Does Someone End the Hospice Benefit and Return to Curative Treatment?
If someone decides they want to return to curative treatment, they have the right to stop hospice at any time and should speak with their doctor if they are interested in stopping. The patient will be asked to sign a form that includes the date such care will end. Afterwards, they will again receive Medicare the way they did before choosing hospice.
Make sure to provide written proof of the change to any respective Medicare Advantage or stand-alone Prescription Drug Plan so that the patient’s status can be updated in the respective system.
The patient can elect hospice again later if they continue to meet the eligibility requirements.
For more information go to:
Or, for anyone covered under a Medicare Advantage Plan, they can also always refer to their plan’s Evidence of Coverage and/or contact their respective Medicare Advantage Plan for additional assistance.