Does Medicare Cover 24-Hour In-Home Hospice Care?

Hospice care offers a specialized approach for individuals facing a life-limiting illness, focusing on comfort and enhancing quality of life rather than pursuing curative treatments. Medicare plays a significant role in making these services accessible, serving as a primary payer for hospice care. This article clarifies Medicare’s coverage of hospice care, with a particular focus on services provided within the home environment.

What Medicare Hospice Care Is

The Medicare Hospice Benefit is a provision under Medicare Part A. This benefit provides comprehensive comfort and support to individuals and their families when a life-limiting illness no longer responds to curative interventions. The central goal of hospice care is palliative care, prioritizing the management of pain and other challenging symptoms. While care is most often delivered in the individual’s home, it can also be provided in inpatient hospice facilities, hospitals, or nursing homes, adapting to the specific needs of the patient.

Eligibility for Medicare Hospice

To qualify for Medicare hospice benefits, an individual must meet specific criteria. A primary requirement is a certification from a doctor indicating that the individual has a terminal illness with a prognosis of six months or less. This medical prognosis must be supported by clinical documentation. A second criterion is the individual’s choice to receive hospice care, opting for comfort-focused palliative care instead of curative treatments.

Individuals retain the flexibility to discontinue hospice care at any point if they wish to resume curative treatment for their illness. They can later re-elect the hospice benefit if they continue to meet eligibility requirements. Initial certification requires two physicians: the individual’s attending physician and the hospice medical director. For subsequent benefit periods, a hospice physician or nurse practitioner must perform a face-to-face encounter to re-certify continued eligibility.

Services Covered by Medicare Hospice

Medicare hospice coverage encompasses a broad range of services to provide comfort and manage symptoms related to the terminal illness. Physician services are included, covering care from the hospice medical director and other hospice team physicians. Skilled nursing care is provided intermittently, offering symptom management, patient and family education, and overall support.

Continuous Home Care (CHC) addresses the need for intensive support during periods of crisis. This level of care is provided for short durations, between 8 and 24 hours per day, to manage acute medical symptoms such as severe pain or uncontrolled nausea. CHC is primarily provided by skilled nursing staff, supplemented by home health aides, to stabilize the patient’s condition at home. Continuous Home Care is temporary and symptom-driven, not routine 24/7 personal or custodial care.

The benefit also covers necessary medical equipment, including hospital beds, wheelchairs, and oxygen equipment. Medications for pain management and symptom control related to the terminal illness are included. Various therapies like physical, occupational, and speech-language pathology services are covered to manage symptoms or maintain functional abilities.

Medical social services offer counseling and support for the individual and family, addressing emotional and social concerns. Home health aide and homemaker services assist with personal care, such as bathing and dressing, but do not include round-the-clock personal care. Spiritual and grief counseling are provided for the individual, and bereavement counseling for the family after passing. Short-term inpatient care is covered for pain or symptom management that cannot be effectively handled at home. Respite care provides short-term inpatient stays to offer a temporary break for the primary caregiver.

What Medicare Hospice Does Not Cover

Medicare hospice benefits do not cover all medical services, particularly those unrelated to comfort or symptom management. Treatment intended to cure the terminal illness is not covered once an individual elects hospice care. This also applies to prescription drugs meant to cure the illness rather than manage pain or symptoms.

Care provided by healthcare professionals or facilities not arranged by the hospice team will not be covered by the hospice benefit. While hospice can be provided in various settings, Medicare does not cover room and board costs if the individual resides in their home, a nursing home, or an assisted living facility. Exceptions for room and board coverage are limited to short-term inpatient care or respite care, which are specifically covered as part of the hospice benefit. Hospital inpatient stays or ambulance transportation not arranged by the hospice team are not covered.

Enrolling in Medicare Hospice

Once an individual meets the eligibility requirements for Medicare hospice, the enrollment process involves several steps to access the benefit. The first step involves selecting a Medicare-approved hospice agency. These agencies are responsible for providing or coordinating all covered hospice services.

Following the selection, the chosen hospice agency will work to confirm the individual’s eligibility with their physician. This includes verifying the terminal illness prognosis and ensuring necessary medical documentation. After eligibility is confirmed, the individual or their authorized representative must sign an election statement. This statement formalizes the choice to receive hospice care and acknowledges understanding of the benefit’s scope.

Upon enrollment, the hospice team conducts an initial assessment to develop a personalized plan of care. This plan outlines the specific services and support the individual will receive, tailored to their unique needs and preferences. For Medicare payment purposes, the hospice must submit a Notice of Election (NOE) within five calendar days after the effective date of election. This ensures the hospice agency receives payment for services.