Medicare’s hospice benefit is a special part of Medicare’s payment for hospice. If you or a loved one has Medicare and are considering hospice, this article explains what you need to know about how Medicare covers hospice.
To qualify for hospice coverage, your life expectancy must be less than six months. However, if you live longer than six months, you can continue to receive hospice benefits as long as your hospice doctor recertifies that you are terminally ill. Recertification occurs initially after 90 days and 180 days, and every 60 days thereafter.
Additionally, you must agree to forego further treatment options for your terminal illness and instead choose treatment options designed to make you comfortable and maintain as good a quality of life as possible. However, if you decide you do want to be treated for a terminal illness, you can choose to end your hospice coverage and revert to regular Medicare coverage at any time.
If you have Medicare and choose a Medicare-certified hospice provider to provide hospice care, almost all of your expenses will be covered.
What Medicare Hospice Benefits Cover
Medicare hospice benefits cover all care related to your terminal illness and can keep you comfortable as long as you get care from a Medicare-approved hospice provider.It pays:
- Hospice doctors and nurses.
- Medicines necessary to make you feel comfortable and to control or prevent symptoms.
- Hospice home health aides help with bathing and changing beds.
- Provide you with the medical equipment you need for comfort, such as a wheelchair or hospital bed.
- Social workers help you manage your affairs and help you and your family deal with emotional difficulties and grief.
- Respite care is needed to give your carer a break.
- Speech, occupational or physical therapy is needed to keep you comfortable or teach you how to cope with the changes your body is going through.
- Provide nutritionist services when necessary.
- Grief counseling for you and your loved ones.
- Hospitalization for crisis management as necessary, approved by the hospice team, and accepted at a hospital or hospice facility contracted with your hospice organization.
- Anything else the hospice team deems necessary has to do with keeping you comfortable and limiting terminally ill symptoms.
what it does not include
Medicare hospice benefits do not cover any conservation your terminal illness. For example, it may cover the cost of radiation therapy aimed at shrinking a tumor compressing the spinal cord causing pain. However, it does not include radiation therapy designed to cure your disease. The key is whether the treatment is to control your symptoms so that you are comfortable (covered) or whether the treatment is to cure your terminal illness (not covered).
Medicare hospice benefits do not cover room and board, except for short-term hospital stays or respite care of up to five days at a time as arranged by the hospice team. This is usually not a problem if you are in your own home and hospice care is usually provided.
However, if you are in a nursing home, assisted living facility, boarding and nursing home, or hospice, you will be responsible for paying for your room and board. If it is obvious that you need to live in a nursing home, assisted living or hospice, but cannot afford room and board, some hospice organizations will use charitable donations to help you cover these costs. This is usually done on a case-by-case basis, so if you predict this might be an issue, ask about it when choosing which hospice organization to use. Depending on your financial situation, you may also find that Medicaid may cover room and board costs associated with nursing homes.
Medicare hospice benefits do not cover emergency room and ambulance services unless your hospice team deems them necessary and arranges for you to receive them, or unless they are not related to your terminal illness (for example, you are in hospice) due to a terminal cancer diagnosis , but then you fell and broke your leg and needed to be taken to the emergency room for treatment unrelated to your cancer).
fees you have to pay
You will get a small drug copay of $5, but some hospice agencies waive this copay. You may have 5% coinsurance (meaning you pay 5% of Medicare-approved costs) for any respite care costs. If you have a Medigap plan, it will cover some or all of your out-of-pocket costs for hospice.
You will pay the Medicare Part B deductible and coinsurance for any doctor services you provide from a doctor who does not work for your hospice. If you receive hospital treatment not related to your terminal illness, you will be responsible for the normal Part A deductible (if you have a Medicare Advantage plan and choose to keep it, you will pay the plan’s normal cost-sharing Inpatient or outpatient care not related to a terminal condition and therefore not covered by your hospice benefit).
You will continue to pay any Medicare premiums you paid prior to enrolling in hospice. This includes your Medicare Part B premium, and your Part D and/or Medigap policy or Medicare Advantage plan premiums, if you have them.
How Medicare Hospice Benefits Work
Medicare hospice benefits are part of Medicare Part A. When you enroll in hospice, whether you are enrolled in Original Medicare or a Medicare Advantage Plan (such as a Medicare HMO), you will automatically (in most cases) receive Original Medicare hospice benefits (with some exceptions, in the pilot described below) intend).
If you are enrolled in a Medicare Advantage plan and you need hospice care, you may choose to remain in the plan as long as you continue to pay your premiums, and the Medicare Advantage plan will continue to meet your unrelated health care needs based on your hospice needs or Your terminal condition (or you may choose to get care through Original Medicare that is not related to your terminal illness, and the regular deductibles and coinsurance that apply to that coverage).
But the Centers for Medicare and Medicaid Services has launched a pilot program starting in 2021 to allow Medicare Advantage to include hospice benefits. For participating insurers, the program allows Medicare Advantage beneficiaries to receive hospice care through their existing insurance plan, in coordination with the care they receive from other services.
The Medicare Advantage Hospice Benefit Pilot Program is part of the Value-Based Insurance Design (VBID) model that provides benefits to approximately 3.7 million Medicare beneficiaries through 2022. In total, there are more than 63 million Medicare beneficiaries in the United States; approximately 42% have a Medicare Advantage plan. As a result, most Medicare Advantage enrollees are enrolled in plans that follow the normal process of having beneficiaries receive hospice benefits through Original Medicare, rather than being part of the VBID pilot program.
So, in most cases, if you are enrolled in Medicare and you need hospice care, it will be provided by Original Medicare Part A. Medicare will pay the hospice organization a certain dollar amount based on each day you spend as a patient. This fixed daily rate in USD is called the daily rate.
The hospice organization pays all of your necessary hospice expenses from its per diem. It gets the money every day, whether or not a hospice nurse or home health aide comes to see you that day.
Hospice organizations now act a bit like HMOs in that you can only get health care related to your terminal illness from that hospice, or from other health care providers contracted with them. For example, if you need home oxygen and hospital beds, you cannot get them from any medical equipment provider of your choice. Instead, you must get them from a medical device provider that contracts with your hospice organization, and your hospice must agree that you need these items.
You may still get health care from non-hospice providers that are not related to your terminal illness. For example, if your terminal illness is cancer, you may continue to see your cardiologist to treat your arrhythmia because it has nothing to do with your terminal illness. The hospice will not pay the cardiologist from the per diem because that doctor’s visit is not related to your terminal illness. However, Original Medicare Part B will pay for cardiologist visits as it has in the past (or, if you have a Medicare Advantage plan and keep it in place, it will cover cardiologist visits under the plan’s normal terms).
In another example, if your terminal illness is pulmonary hypertension and you need to be hospitalized because you tripped and broke your hip, Original Medicare Part A will pay for your hip-related hospitalization, Original Medicare Part B will pay the doctor’s bill associated with you If you have an Advantage plan and choose to keep it after you choose Medicare’s hospice benefits, your buttocks or your Medicare Advantage plan will cover your buttocks treatment.
Therefore, Medicare will pay for your terminally ill palliative care (using Medicare hospice benefits) and for health care not related to your terminal illness (using Medicare Parts A and B, or your Medicare Advantage plan), subject to normal costs – Share requests for services you need.
what happens if you change your mind
If you change your mind about hospice after enrolling, you can withdraw your Medicare hospice coverage and continue to receive care from Original Medicare or a Medicare Advantage plan (if you are enrolled).
You can switch to a different hospice organization if you want to continue hospice services but have changed your mind about the hospice organization of your choice. However, you cannot change hospice at any time. You can change it once for the first 90 days of care, once for the next 90 days, and every 60 days thereafter. Hopefully, you will be able to find a hospice organization that you are happy with and will not need to change.
Medicare has strong hospice benefits. It can be used by any beneficiary diagnosed with a terminal illness, as long as a doctor certifies that they have a life expectancy of less than six months. In most cases, hospice benefits are provided through Original Medicare (Part A), even for beneficiaries enrolled in a Medicare Advantage plan. But a pilot program, starting in 2021, will allow some Medicare Advantage plans to offer hospice benefits directly to their enrollees.
If you or a loved one on Medicare needs hospice care, rest assured that the plan offers strong hospice benefits. Your costs will be minimal and will cover all necessary palliative care. In addition to hospice care, Medicare will continue to provide these benefits as usual if treatment is required for an illness not related to a terminal illness. Medicare hospice benefits also include inpatient respite care so your regular caregivers have a chance to rest.