Does Medicare Pay for Hospice in a Skilled Nursing Facility?
Understand Medicare's coverage for hospice services provided within a skilled nursing facility, including covered care and patient responsibilities.
Hospice care offers comfort and support to individuals with life-limiting illnesses, focusing on quality of life rather than curative treatments. Skilled nursing facilities (SNFs) provide skilled nursing care and rehabilitation services. This article explores Medicare’s coverage for hospice services when provided within an SNF setting.
Hospice Eligibility Under Medicare
To receive Medicare hospice services, an individual must meet specific eligibility requirements. A doctor and a hospice medical director must certify the patient is terminally ill, indicating a life expectancy of six months or less if the illness progresses naturally. This prognosis is based on clinical judgment and supporting documentation.
The patient must choose comfort-focused care, known as palliative care, over treatments aimed at curing their illness. This election means Medicare will no longer cover curative treatments for the terminal illness and related conditions. However, Medicare continues to cover treatments for conditions unrelated to the terminal diagnosis.
The patient or their authorized representative must sign a statement electing the hospice benefit from a Medicare-approved hospice provider. Eligibility for hospice care is distinct from the criteria for a skilled nursing facility stay covered under Medicare’s separate SNF benefit.
Medicare Coverage Details for Hospice in a Skilled Nursing Facility
When an individual eligible for Medicare Hospice Benefits resides in a skilled nursing facility, Medicare directs payment to the hospice provider. The hospice provider then assumes responsibility for the patient’s room and board costs within the SNF, along with delivering all hospice-related care. This ensures seamless integration of services.
The Medicare Hospice Benefit includes nursing care, medical supplies, and necessary equipment. Medications for pain management and symptom control related to the terminal illness are also covered.
Additional covered services include hospice aide and homemaker services, physical and occupational therapy, speech-language pathology, and social worker services. Dietary counseling and grief and bereavement counseling for both the patient and family members are also part of the benefit. Short-term inpatient care for acute pain or symptom management, which cannot be effectively managed in the SNF, is covered. Respite care, offering temporary relief for caregivers, is also included for short periods, typically up to five consecutive days.
If a patient has elected hospice, the skilled nursing facility does not directly bill Medicare for the patient’s stay under its Part A benefit for hospice-related care. The hospice benefit takes precedence, covering all aspects of hospice care, including room and board in the SNF. However, if the patient has skilled care needs unrelated to their terminal illness and meets Medicare’s SNF coverage requirements, Medicare may cover those specific services and associated room and board.
Specific items and services not covered by the hospice benefit when a patient is in an SNF include treatment intended to cure the terminal illness. Prescription drugs not for symptom control or pain relief related to the terminal illness are generally excluded from hospice coverage. Care from another provider not arranged or approved by the hospice team will not be covered.
Understanding Patient Financial Responsibilities
Medicare covers 100% of the cost of hospice care with limited exceptions. There are no deductibles or premiums for hospice care under Medicare.
Patients may encounter minimal out-of-pocket costs for certain services. A copayment, not exceeding $5 per prescription, may apply to outpatient prescription drugs for pain and symptom management. A 5% copayment of the Medicare-approved amount is required for inpatient respite care.
The hospice provider handles all billing directly to Medicare. Patients should not receive separate bills for hospice services from the skilled nursing facility or other providers if those services are part of the established hospice plan of care. Patients should discuss any potential costs with their chosen hospice provider.