Medicare Hospice Benefits
By the GWAAR Legal Services Team
Hospice care focuses on comfort, symptom control, and pain relief for patients with a life-limiting illness. Services provided by the hospice team relate to caring for the individual, rather than curing a condition or disease. Support is available to the patient as well as family members and caregivers. A person is eligible for hospice benefits under Medicare if he or she has a life expectancy of six months or less, as certified by a doctor. The person must also be enrolled in Medicare Part A to be eligible for hospice benefits paid by Medicare. The election into hospice is not required—it’s entirely optional--and requires an affirmative election in writing signed by the patient. By electing into hospice, a patient acknowledges that Medicare will no longer cover treatment or medications intended to cure the person’s terminal illness and related conditions.
A person can remain in hospice longer than six months if his or her medical provider recertifies that the person remains terminally ill. Likewise, a person can opt-out of hospice at any time. If a person’s health improves, or an illness goes into remission, the person may no longer need hospice care.
The Medicare hospice benefit includes a comprehensive care team consisting of a doctor, nurse, social worker, physical and occupational therapists, counselors, hospice aides, chaplains, and volunteers. Other covered hospice benefits include 24/7 crisis response, respite care, durable medical equipment and supplies, prescription drugs for symptom control and pain relief, and grief counseling for family members and care-givers after a person passes away. A person’s hospice team will work with the person to set up a plan of care to ensure all of the person’s needs are met.
Out-of-pocket costs under hospice care are low. The Medicare Part A deductible does not apply to hospice benefits and services. A person enrolled in hospice pays 5% coinsurance on medications up to a maximum of $5 per drug, and 5% coinsurance for short-term inpatient respite care. If a person enrolled in hospice chooses to receive care or treatment for health problems that are not related to the terminal illness, that would still be covered under Original Medicare and deductibles and coinsurance would apply.
Hospice care is generally provided in a person’s home. Room and board is not a covered benefit under hospice. A person who requires inpatient care in a nursing home or other care setting needs to private pay or apply for Medicaid. An exception to this rule is the 5-day caregiver respite benefit, which provides inpatient care on an occasional basis.
Hospital inpatient stays, emergency room visits, and ambulance transportation are typically not covered under hospice. The only way to get Medicare coverage for these services is if they are written into the person’s hospice plan of care and arranged by the hospice provider. For example, if a person’s pain cannot be managed in their home setting, the hospice plan of care could include an overnight stay in a hospital so that medical professionals can utilize more intensive interventions to better control or minimize pain.
Medicare hospice benefit FAQ’s
Q: Because hospice benefits are covered under Medicare Part A, should I drop Medicare Part B and D and my supplement policy after electing into hospice?
A: It is advantageous to keep Part B, Part D, and a Medicare supplement policy in place, even if a person is on hospice. Hospice only pays for care and services related to the terminal illness, including comfort care and pain management. If a person broke an arm or developed a urinary tract infection, that person may need medical treatment that is unrelated to the terminal condition. In that case, Original Medicare would provide coverage, but it would be subject to the standard deductibles and coinsurance under Original Medicare. For example, Part B would cover outpatient services under the 80/20% coinsurance structure. A Medicare supplement would cover the remaining 20%. In addition, a Medicare supplement will cover the 5% coinsurance for hospice covered drugs and respite care. Finally, if a person drops Medicare Part B, but then recovers from his or her illness and is not recertified for continuing hospice benefits, that person would have to wait until the Medicare General Enrollment Period (January through March each year) to enroll in Medicare Part B. That person’s Part B would then start the following July, which means a person may go up to 16 months without Part B.
Q: How should I select a hospice provider?
A: First and foremost, ask if the hospice provider is Medicare-approved. If the provider is not Medicare approved, then Medicare will not cover the services and benefits received. It may be helpful to know whether the doctors, nurses, and nurse practitioners are certified in palliative care. Caregivers may want to know what the provider’s arrangements are for inpatient respite stays—does the hospice provider have its own facility or an arrangement with a nearby facility? How fast is the crisis response? Word of mouth may also provide insight into prior experiences with that agency.
Q: If a person elects hospice, does he/she have to change doctors?
A: No. Usually a person can keep his or her same doctor after electing into hospice.
Q: Should a person only opt into hospice in the last few days of their life?
A: No. Hospice provides a wide range of services to the patient, family, and caregivers - all of which are available within the last six months of a person’s life expectancy. The sooner hospice gets involved, the more help they are able to provide. Most people state that they wish they had involved hospice sooner.
Copyright GWAAR, 2018