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The Medicare program is a government administered health insurance program offered to American citizens who meet specific age and income requirements, and sometimes is offered to those who qualify due to disability.
The Medicare Hospice Benefit was created for Hospice and Medicare eligible patients. As Gulfside Hospice provides services to individuals with life-limiting illness regardless of ability to pay, the Medicare Hospice Benefit is an valuable funding source for our patients without other insurance.
The Medicare Program consists of two parts, Part A and Part B, which provide different services and benefits under their individual parts. Traditionally, Part A insures Hospital, Home Health, and Nursing Home services. The Medicare Hospice Benefit also falls under this part of the Program. Part B covers medical insurance, for example, doctor’s visits.
Medicare Hospice Benefit
Patients who opt for this benefit choose to receive non-curative treatment and services for their Hospice-related diagnoses, while still accessing treatment of otherwise unrelated health problems.
The patient must have Medicare Part A and a limited prognosis. The attending physician and the Hospice medical director must certify that given the natural course of the disease, the patient probably will succumb to the illness within six months. If the patient survives the illness longer than expected, the benefit will continue as long as the Hospice physician member of the interdisciplinary team recertifies the patient’s life is still limited. However, if the patient’s condition improves and the patient’s life expectancy improves, the patient is discharged from Hospice and returned to the traditional Medicare program.
An amendment to the Social Security Act in 2000 clarified and loosened the benefit’s definition of “terminally ill” to embrace patients earlier in the course of their illness and better serve them through the Hospice program. Therefore, the amendment emphasized the physician’s clinical judgment of the illness as the criteria for staying in Hospice.
However, since many physicians remain unaware of the amendment, a large number of patients continue to enter Hospice at a very late stage, depriving both patient and loved ones of valuable Hospice benefits.
Each Hospice is responsible for the services that are related to the diagnosis, are deemed “reasonable and necessary” for the palliation of symptoms, and are included in the plan of care. Patients receive, at no expense; medications, oxygen, special beds, radiation therapy, chemotherapy, counseling, hospitalizations, short nursing home stays, and home health aides.
Patients retain full Medicare coverage for any health care need not related to the hospice diagnosis. For example, a patient with end-stage COPD who falls and breaks a hip would receive all therapies and treatments for the hip from traditional Medicare since the illness was unrelated to the hospice diagnosis. However, the patient must continue to pay the applicable deductible and coinsurance amounts under the original Medicare plan or the co-payments under a Medicare managed care plan.
Services Covered through the Hospice Medicare Benefit
- Nursing services
- Physician services to provide palliation and management of the Hospice illness and related conditions
Social services
- Counseling services to include:
- Spiritual counseling provided by clergy
- Bereavement counseling for 13 months after the death of the patient
- Mental health counseling
- Spiritual counseling provided by clergy
- Home health aide services
- Homemaker services
- Volunteer support to assist the patient and loved ones
- Complementary therapies
- Medical supplies, such as:
- Pharmaceuticals related to the Hospice diagnosis
- Durable medical equipment (ie: wheelchairs, hospital beds)
- Any other medical supplies (i.e. bandages, catheters)
- Pharmaceuticals related to the Hospice diagnosis
- Physical therapy
- Respiratory therapy
- Diagnostic studies related to the care of the illness
- Laboratory studies
- Radiologic tests
- Diagnostic studies related to the care of the illness
Services that are not covered include services or medications unrelated to the diagnosis, services not “reasonable or necessary” for palliative care, and services not “called for” in the plan of care.
Because Medicare rules give Hospices clear authority to refuse to pay for treatments not included in the Hospice Care Plan, it is important for attending physicians to communicate well with the patient’s Hospice Care Team.
Physician Reimbursement
Physician reimbursement of the patient’s attending physician is simple. The doctor bills traditional Medicare Part B for his or her services. However, services the doctor provides relating to the Hospice diagnosis are billed directly to the patient’s Hospice.
Any consultants working on the patient’s case will bill their diagnosis-related visits to Hospice.
Return to Regular Medicare
A patient may opt out of Hospice care at any point and return to receiving all regular Medicare benefits. While the patient is in Hospice, they will continue to pay applicable deductibles and/or co-payments for services unrelated to the Hospice diagnosis.
For More Information
For more detailed information, visit the Medicare website at www.medicare.gov .
The booklet, “Medicare Hospice Benefits” is available on-line at that site (see Publications), or may be ordered as follows:
- Request: “Medicare Hospice Benefits”
- Publication No. CMS 02154, Revised July 2002
- US Department of Health & Humans Services
- Centers for Medicare & Medicaid Services
- 7500 Security Boulevard
- Baltimore, MD 21244-1850