Hospice care provides crucial support and comfort for individuals facing a terminal illness. If you or a loved one are exploring hospice services, understanding Medicare coverage is essential. This guide clarifies Which Part Of The Medicare Program Covers Hospice Care, outlining eligibility, covered services, and levels of care to help you navigate this important benefit.
Medicare Part A: Your Hospice Benefit
The part of the Medicare program that covers hospice care is Medicare Part A (Hospital Insurance). While Part A primarily covers inpatient hospital stays, skilled nursing facility care, and home health services, it also encompasses hospice benefits for those who meet specific criteria. This means that if you are enrolled in Medicare Part A, you have access to hospice care as part of your coverage.
To be eligible for Medicare hospice benefits under Part A, several conditions must be met:
- Medicare-Certified Hospice: You must receive care from a hospice agency that is certified by Medicare. This ensures the hospice meets specific standards of care and quality.
- Terminal Illness Certification: Both your attending physician (if you have one) and the hospice physician must certify that you are terminally ill. This means you have a medical prognosis of 6 months or less to live if your illness progresses normally.
- Hospice Benefit Election: You need to sign a statement choosing the hospice benefit. By doing so, you agree to focus on comfort care rather than curative treatments for your terminal illness. Electing the hospice benefit also means you waive your right to other Medicare payments for treatments related to your terminal condition while under hospice care.
Once you are certified and elect the hospice benefit, your coverage periods are structured as follows:
- Initial Coverage: You can elect hospice for two 90-day periods.
- Subsequent Coverage: Following the initial 90-day periods, you can receive an unlimited number of subsequent 60-day periods.
For benefit periods beyond the initial 180 days (two 90-day periods), Medicare requires a face-to-face (FTF) encounter. This encounter, conducted by a hospice physician or nurse practitioner, must occur before each recertification starting with the third benefit period and every period thereafter. The FTF encounter ensures ongoing assessment and documentation to support the patient’s continued eligibility based on a life expectancy of 6 months or less.
Services Included Under Medicare Hospice Coverage
Medicare’s hospice benefit is comprehensive, designed to provide holistic care addressing the physical, emotional, and spiritual needs of both the patient and their family. The services covered under Part A hospice include:
- Physician Services: Services from hospice-employed physicians, nurse practitioners, and your chosen attending physician to oversee and manage your care.
- Nursing Care: Skilled nursing care to manage symptoms, administer medications, and provide overall medical support.
- Medical Equipment and Supplies: Coverage for necessary medical equipment such as hospital beds, wheelchairs, and oxygen, as well as medical supplies related to your care.
- Medications for Pain and Symptom Management: Drugs prescribed to alleviate pain and manage symptoms related to your terminal illness.
- Hospice Aide and Homemaker Services: Assistance with personal care and household tasks to support daily living.
- Therapy Services: Physical therapy, occupational therapy, and speech-language pathology services to help maintain function and comfort.
- Medical Social Services: Support from medical social workers to address emotional, social, and practical challenges faced by patients and families.
- Dietary Counseling: Nutritional guidance tailored to the patient’s needs and preferences.
- Spiritual Counseling: Spiritual support and counseling services to address spiritual concerns and provide comfort.
- Grief and Loss Counseling: Individual and family counseling to help cope with grief and loss, both before and after the patient’s death.
- Short-Term Inpatient Care: Coverage for short-term inpatient care for pain control, symptom management, and respite care for caregivers.
It is important to note that all hospice care and services are provided according to an individualized plan of care (POC). This POC is developed collaboratively by the hospice interdisciplinary group, the attending physician (if any), the patient or their representative, and the primary caregiver, ensuring that care is tailored to the patient’s specific needs and wishes.
Levels of Hospice Care Covered by Medicare
Medicare recognizes four distinct levels of hospice care, each designed to meet varying patient needs. The daily payment to hospice agencies by Medicare is based on the level of care provided:
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Routine Home Care: This is the most common level of hospice care, provided when a patient chooses to receive hospice care at home. “Home” can be a private residence, assisted living facility, or nursing home. Routine home care is for patients who are not in acute crisis.
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Continuous Home Care: This level is for patients experiencing a brief period of crisis and require intensive care to remain at home. Continuous home care is primarily nursing care provided in the patient’s home for a majority of the day. Hospice aides and homemakers can also provide continuous care under this level.
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Inpatient Respite Care: Respite care offers temporary inpatient care in an approved facility, providing a break for the patient’s caregiver. Medicare covers up to 5 consecutive days of respite care.
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General Inpatient Care: General inpatient care is for managing severe pain or symptoms that cannot be effectively managed at home or in other settings. This level of care is provided in an inpatient facility such as a hospital or hospice inpatient unit.
Hospice Coinsurance Under Medicare Part A
While Medicare Part A covers a significant portion of hospice costs, there are some coinsurance responsibilities for patients:
- Prescription Drugs for Symptom and Pain Management: For each prescription for palliative drugs related to the terminal illness received during routine home care or continuous home care, there is a small coinsurance. This coinsurance is 5% of the drug cost to the hospice, and it is typically capped at $5 per prescription. There is no coinsurance for drugs during general inpatient care or respite care.
- Respite Care: For inpatient respite care, the patient’s daily coinsurance is 5% of the Medicare payment for respite care days. This coinsurance is capped at the inpatient hospital deductible amount for the year in which the hospice care began. This level of care includes room and board within the respite facility.
Understanding which part of Medicare covers hospice care, the services included, and the different levels of care can empower you to make informed decisions about end-of-life care. Medicare Part A provides a robust hospice benefit designed to support patients and families during a challenging time, focusing on comfort, dignity, and quality of life.
