Does Medicare Pay If the Patient Is in Hospice?

Medicare Coverage for Hospice Care

Medicare provides coverage for hospice care when a patient is terminally ill. This benefit supports end-of-life care, shifting the focus from curative treatments to comfort and symptom management. Hospice care aims to enhance the quality of life for individuals nearing their end of life and offers support to their families. This approach helps ensure patients are comfortable and pain-free, often allowing them to remain in their preferred setting.

Qualifying for Medicare Hospice Benefits

To be eligible for Medicare hospice benefits, a patient must meet specific criteria. The patient must have Medicare Part A, which covers hospital insurance. Both the patient’s attending physician and a hospice medical director must certify that the patient is terminally ill, indicating a life expectancy of six months or less if the illness progresses naturally. This prognosis is based on the physician’s clinical judgment, and supporting documentation must be maintained in the hospice medical record.

A patient must also choose to receive comfort-focused hospice care instead of continuing curative treatment for their terminal illness. This choice signifies a change in the goal of care from attempting to cure the illness to managing symptoms and providing support. Patients or their authorized representatives are required to sign an election statement to formally choose the hospice benefit.

Medicare hospice benefits are structured into specific periods. Initially, patients are eligible for two 90-day benefit periods. Following these, an unlimited number of 60-day benefit periods may be available. For subsequent benefit periods, a hospice physician or nurse practitioner must conduct a face-to-face encounter with the patient to re-certify continued eligibility based on the life expectancy criteria.

Understanding Covered Hospice Services

Medicare’s hospice benefit encompasses a wide array of services designed to provide comfort and manage symptoms for terminally ill patients. These services are delivered by a team of professionals focused on the patient’s and family’s overall well-being. Covered services include:
Physician and nursing care, often involving intermittent visits and 24/7 availability for urgent needs.
Medical equipment (e.g., wheelchairs, hospital beds, walkers) and necessary medical supplies (e.g., bandages, catheters).
Prescription drugs for pain relief and symptom management.
Hospice aide and homemaker services for personal care and daily activities.
Therapeutic services like physical, occupational, and speech-language pathology for symptom control or maintaining functional abilities.
Medical social services and dietary counseling.
Grief and loss counseling for the patient and their family, extending after the patient’s death.
Short-term inpatient care for acute symptom management and respite care for temporary caregiver relief.

Services Not Covered by Medicare Hospice

While Medicare’s hospice benefit is comprehensive, certain services are excluded. Once a patient elects hospice care, treatment intended to cure the terminal illness is not covered. This is a fundamental aspect of the hospice election, as the focus shifts entirely to comfort and palliative care.

Prescription drugs not related to the terminal illness or its symptom management are not covered under the hospice benefit. Care provided by healthcare professionals or facilities not arranged or authorized by the hospice team is excluded from coverage. This means that seeking care from outside providers for hospice-related needs without prior coordination could result in out-of-pocket expenses.

Room and board costs are not covered by Medicare hospice benefits if the patient resides in a nursing home, assisted living facility, or their own home. However, if short-term inpatient care or respite care is determined necessary and arranged by the hospice team, the stay in the facility for those specific purposes would be covered. Emergency room visits or inpatient hospital stays that are not arranged by the hospice team or are for curative purposes related to the terminal illness are also not covered.

Out-of-Pocket Costs for Hospice Care

Medicare covers most hospice care costs, resulting in minimal out-of-pocket expenses for the patient. For most hospice services, patients pay nothing.

There are two instances where a patient might incur a copayment. A copayment of up to $5 may apply for each prescription drug used for pain and symptom management. For inpatient respite care, which offers temporary relief for the primary caregiver, a patient may pay 5% of the Medicare-approved amount. Some hospice providers may choose to waive these copayments. No deductibles or premiums are required for hospice care under Medicare Part A.

Accessing Medicare Hospice Benefits

Initiating Medicare hospice benefits involves a clear process to ensure proper enrollment and care coordination. The first step is selecting a Medicare-approved hospice program. This choice is important as all care related to the terminal illness must be provided or arranged by that chosen hospice.

After selecting a hospice, the patient’s attending physician and the hospice medical director must certify the patient’s terminal illness. This certification formally establishes eligibility for the hospice benefit. The patient, or their authorized representative, then signs an election statement. This document confirms their choice to receive hospice care and understand the shift from curative treatment to comfort care.

Once enrolled, the hospice team develops an individualized plan of care in collaboration with the patient, their attending physician, and primary caregiver. This plan guides the provision of services tailored to the patient’s needs. Patients maintain the right to change hospice providers once during each benefit period. A patient can choose to stop hospice care at any time, and if still eligible, they may re-enroll later.