Does Medicare Pay for a Hospice Facility?

Hospice care provides a specialized approach for individuals with a terminal illness, focusing on comfort and quality of life rather than curative treatments. This comprehensive support system addresses medical, emotional, and spiritual needs for both the patient and their family. Medicare, a federal health insurance program, helps cover the costs of hospice care for eligible beneficiaries.

Medicare Hospice Benefit Eligibility

To qualify for Medicare’s hospice benefit, an individual must be enrolled in Medicare Part A (Hospital Insurance). A physician must certify that the individual has a terminal illness, indicating a medical prognosis of six months or less to live if the illness runs its normal course. This certification requires input from both the patient’s attending physician and a hospice physician.

A person must also choose to receive hospice care, electing palliative care for comfort and symptom management instead of pursuing curative treatments. This choice involves signing a statement acknowledging that, for the terminal illness and related conditions, Medicare will pay only for services provided or arranged by the chosen hospice provider. Hospice care must be received from a Medicare-certified hospice program. The benefit begins with two 90-day periods, followed by an unlimited number of 60-day periods, all requiring ongoing physician recertification.

Covered Services and Settings

The Medicare Hospice Benefit covers a wide array of services to manage pain and symptoms related to a terminal illness and its associated conditions. These services include:
Physician services
Skilled nursing care
Medical equipment
Medications for pain relief and symptom control
Hospice aide and homemaker services
Various therapies like physical or occupational therapy
Medical social services
Dietary counseling
Spiritual counseling
Grief counseling for the patient and family

While hospice care is most frequently provided in a patient’s home or other residential settings, such as a nursing home, Medicare covers short-term inpatient care when medically necessary. This inpatient care is for acute pain control or symptom management that cannot be effectively managed elsewhere. It can be provided in a Medicare-approved hospice facility, hospital, or skilled nursing facility. Medicare also covers short-term inpatient respite care, allowing a caregiver a temporary break for up to five consecutive days. Respite care can be provided in a Medicare-approved nursing home, hospice inpatient facility, or hospital, though a small copayment of up to 5% of the Medicare-approved amount may apply, not to exceed the inpatient hospital deductible for the year. Room and board costs are generally not covered by Medicare if the patient is living in their own home, a nursing home, or a hospice inpatient facility, unless they are receiving these specific short-term inpatient or respite services.

Non-Covered Services

Medicare’s hospice benefit has specific limitations regarding covered services. Once a patient elects hospice, Medicare typically ceases to cover treatments intended to cure the terminal illness itself. This includes prescription drugs meant to cure the illness rather than solely to manage pain or symptoms.

Care received from providers not part of the hospice team, or care not arranged by the hospice provider, is generally not covered. For instance, hospital outpatient or inpatient care, or ambulance transportation, will not be covered unless arranged by the hospice team or if the services are completely unrelated to the terminal illness.

Initiating Hospice Care

Initiating Medicare hospice benefits involves identifying a Medicare-approved hospice provider. The patient’s doctor, along with a hospice physician, must certify that the patient meets the terminal illness criteria.

Following certification, the patient or their authorized representative must sign an election statement. This document confirms the patient’s understanding of hospice care’s palliative nature and their choice to receive care from the designated hospice provider. It also signifies that the patient waives their Medicare rights to payment for services related to their terminal illness from other providers. Despite this, Medicare will continue to pay for covered benefits for any health problems or conditions that are unrelated to the terminal illness. Patients retain the right to change their chosen hospice provider once during each benefit period.