For reprint by 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 re-certifies 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, physician 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 caregivers 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.
For people on a Medicare Advantage plan, the hospice benefits is administered through Original Medicare Part A, not the advantage plan.