Does Medicare Cover Hospice 100 Percent?

Medicare’s hospice benefit supports individuals facing a terminal illness, shifting focus from curative treatments to comfort and quality of life. While Medicare covers most hospice care costs, a small out-of-pocket expense may apply in specific situations. This benefit aims to provide holistic care, ensuring patients are comfortable and pain-free during their final months.

Defining Medicare Hospice Care

Hospice care within the Medicare framework offers comprehensive, holistic support for terminally ill patients and their families. Its primary goal is to provide comfort, manage pain, and offer support rather than attempting to cure the illness. This palliative approach aims to improve the quality of life for individuals in their last stages.

A core component of Medicare hospice care is the interdisciplinary team, which addresses the physical, emotional, social, and spiritual needs of the patient and their family. This team includes doctors, registered nurses, social workers, spiritual counselors, hospice aides, and volunteers.

The Medicare hospice benefit covers various services designed to manage the terminal illness and related conditions. These include medical care, nursing services, necessary medical equipment like wheelchairs or hospital beds, medical supplies such as bandages and catheters, and prescription drugs for pain relief and symptom management. Beyond medical necessities, the benefit extends to support services like hospice aide and homemaker services, physical and occupational therapy, and speech-language pathology services. Social worker services assist with social and emotional concerns, and dietary counseling is available. Grief and loss counseling is offered to both the patient and their family, even after the patient’s passing.

Eligibility for Medicare Hospice

To qualify for Medicare hospice benefits, an individual must be entitled to Medicare Part A.

A physician and a hospice medical director must certify that the patient has a terminal illness. This certification means the medical prognosis indicates a life expectancy of six months or less if the illness runs its normal course.

The patient must choose to receive hospice care, accepting palliative care focused on comfort and symptom management instead of pursuing curative treatment for their terminal illness.

The patient or their authorized representative must sign an election statement. This statement formalizes their choice of hospice care and confirms their understanding of its palliative nature.

What Medicare Hospice Covers and What It Doesn’t

Medicare generally covers nearly all costs associated with hospice care, particularly those services related to the terminal illness and its symptom management.

Many services are typically covered at 100% when provided as part of the hospice plan of care. This comprehensive list includes doctor and nursing services, which are available around the clock. Medical equipment, such as hospital beds and oxygen equipment, along with medical supplies like wound dressings, are fully covered. Prescription drugs specifically used for pain control and symptom relief related to the terminal illness are also included.

Additional fully covered services encompass hospice aide and homemaker services, which assist with daily living activities. Physical and occupational therapy, and speech-language pathology services. Social worker services are provided to assist with social and emotional concerns, and dietary counseling is available. Furthermore, grief and loss counseling is offered to both the patient and their family, extending even after the patient’s passing.

Medicare also covers short-term inpatient care for pain control or acute symptom management that cannot be effectively managed at home. Respite care, which provides short-term inpatient stays to offer a temporary break for the primary caregiver, is also covered.

Despite the broad coverage, there are limited situations where out-of-pocket costs may apply or where services are not covered. Patients may incur a small copayment for prescription drugs used for pain and symptom management, typically no more than $5 per prescription.

A 5% coinsurance is typically required for inpatient respite care, calculated based on the Medicare payment for a respite care day. This coinsurance amount may not exceed the inpatient hospital deductible for the year the hospice coinsurance period began.

Medicare hospice does not cover care from providers not arranged by the hospice team. Additionally, treatment for the terminal illness that is not for pain control or symptom management, meaning curative treatment, is generally not covered once the hospice benefit is elected. Room and board costs in a nursing home or long-term care facility are also typically not covered, unless the stay is for short-term inpatient care or respite care. Care received in an emergency room, inpatient facility, or via ambulance is not covered unless it is arranged by the hospice team or is unrelated to the terminal illness.

How to Elect Medicare Hospice Benefits

Initiating Medicare hospice benefits involves procedural steps. The process begins with physician certification, requiring both the patient’s attending physician and a hospice medical director to certify the terminal illness prognosis.

After certification, the patient or their legal representative must choose a Medicare-approved hospice provider. It is important to ensure the chosen agency is certified by Medicare to receive covered services.

The next step involves signing a Medicare Hospice Election Statement. This document signifies the patient’s informed decision to choose hospice care over curative treatments for their terminal illness. The statement also acknowledges their understanding of the palliative focus of hospice services.

The election statement must identify the specific hospice providing care and the effective date of the election. It also includes an acknowledgement that the patient understands certain Medicare services related to the terminal illness are waived by this election.

Patients retain the right to revoke their hospice benefit at any time. If a patient revokes the benefit, they can return to standard Medicare coverage for all services. Should they later become eligible and wish to resume hospice care, they can re-elect the benefit, provided they continue to meet the eligibility requirements.