Understanding Medicare and Medicaid's Hospice Benefit
Medicare's hospice benefit covers any care that is reasonable and necessary for easing the course of a terminal illness. It is one of Medicare's most comprehensive benefits and can be extremely helpful to both the terminally ill individual and his or her family, but it is little understood and underutilized. Understanding what is offered ahead of time may help Medicare beneficiaries and their families make the difficult decision to choose hospice if the time comes.
The focus of hospice is palliative care, which means helping people who are terminally ill and their families maintain their quality of life. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs while also supporting the terminally ill individual's independence, access to information, and ability to make choices about health care.
To qualify for Medicare's hospice benefit, a beneficiary must be entitled to Medicare Part A, and a doctor must certify that the beneficiary has a life expectancy of six months or less. If the beneficiary lives longer than six months, the doctor can continue to certify the patient for hospice care indefinitely. The beneficiary must also agree to give up any treatment to cure his or her illness and elect to receive only palliative care. This can seem overwhelming, but beneficiaries can also change their minds at any time. It's possible to revoke the benefit and reelect it later, and to do this as often as needed.
Interestingly, Medicaid also offers hospice benefits, but it is for those who do not qualify for Medicare (as a result, most elderly Floridians will get hospice through Medicare). usually Medicaid provides hospice care for those under age 65 with a terminal illness at its end-stage condition.
What Does Hospice Cover?
There are four main levels of Hospice Care:
- Routine Home Care (RHC) with service intensity add-ons depending on what services are needed.
- Continuous Home Care (CHC): CHC is provided during a period of crisis, it is essentially round-the-clock skilled nursing care.
- Inpatient Respite Care (IRC): IRC is short-term care provided to relieve family members or others who usually care for the individual.
- General Inpatient Care (GIC): also short term and used for pain-control that is unable to be provided at home.
Medicare and Medicaid will cover any care that is reasonable and necessary for easing the course of a terminal illness. Hospice nurses and doctors are on-call 24 hours a day, 7 days a week, to give beneficiaries support and care when needed. Services are usually provided in the home. The Medicare hospice benefit provides for:
- Physician and nurse practitioner services
- Nursing care
- Medical appliances and supplies
- Drugs for symptom management and pain relief
- Short-term inpatient and respite care
- Homemaker and home health aide services
- Counseling
- Social work service
- Spiritual care
- Volunteer participation
- Bereavement services
Services are considered appropriate if they are aimed at improving the beneficiary's life and making him or her more comfortable.
Because the beneficiary is electing palliative care over treatment, there are things the hospice benefit will not cover:
- Treatment to cure the beneficiary's illness.
- Prescription drugs other than for symptom control or pain relief.
- Care from a provider that wasn't set up by the hospice team, although the beneficiary can choose to have his or her regular doctor be the attending medical professional.
- Room and board. If the beneficiary is in a nursing home, hospice will not pay for room and board costs. However, if the hospice team determines that the beneficiary needs short-term inpatient care or respite care services, Medicare will cover a stay in a facility.
- Care from a hospital, either inpatient or outpatient, or ambulance transportation unless it arranged by the hospice team. The beneficiary can use regular Medicare to pay for any treatment not related to the beneficiary's terminal illness.
Important Questions to Ask When Selecting a Hospice Provider in Florida
We strongly advise doing your own research to make sure that you are picking the right hospice provider. But here are a sample list of questions to ask when interviewing a hospice:
- Is staff available 24 hours a day, 7 days a week?
- How do you ensure that patients obtain their desired level of comfort?
- Who will direct the hospice patient’s care?
- What education is provided for the patient and caregivers?
- Will you ever override a patient’s advance directive? Under what circumstances?
- How many patient and caregiver complaints were received in the last year? How were they resolved?
- How many patients and caregivers have terminated services? What are the reasons?
The best end-of-life care is based on the individual patient’s values and wishes. For this reason, the importance of advance directives and living wills cannot be overemphasized, so the patient’s wishes are in writing.
Here is a link to an interesting podcast episode on picking the right hospice provider.
Florida Elder Needs Lawyer Hospice Resources
To download Medicare's booklet on the hospice benefit, click the link
To read about Florida Medicaid's hospice benefit, click the link.
To read more about the difference between Medicare and Medicaid, click the link.
