Understanding Hospice Care Under Medicare Part A

Hospice care offers comprehensive comfort and support for individuals facing a terminal illness and their families. Instead of focusing on cures, hospice emphasizes palliative care, aiming to relieve pain and manage symptoms to enhance the quality of life during the final stages of illness. For those with Medicare Part A, understanding hospice benefits is crucial. This guide explains how Medicare Part A covers hospice care, ensuring patients can access this vital support when they need it most.

Eligibility for Hospice Care with Medicare Part A

To be eligible for hospice care benefits under Medicare Part A, several criteria must be met. Firstly, care must be provided by a Medicare-certified hospice agency. Secondly, both the patient’s attending physician (if they have one) and the hospice physician must certify that the patient is terminally ill, with a prognosis of 6 months or less to live if the illness progresses naturally. Finally, the patient must sign a hospice election statement. By signing this, they choose the hospice benefit and agree to waive Medicare payments for curative treatments related to their terminal illness and related conditions.

Once certified and enrolled, a patient can receive hospice benefits for an initial period of two 90-day periods, followed by an unlimited number of subsequent 60-day periods. It’s important to note that after the initial two 90-day periods, for each benefit period recertification (starting from the third period onwards), Medicare requires documentation of a face-to-face (FTF) encounter between the patient and either a hospice physician or a hospice nurse practitioner. This FTF encounter is essential to re-evaluate and document clinical findings that continue to support a life expectancy of 6 months or less, ensuring ongoing eligibility for hospice care.

All hospice care services are delivered according to an individualized plan of care (POC). This plan is meticulously created to meet the specific needs of each patient. The hospice interdisciplinary group, which includes the attending physician (if applicable), the patient or their representative, and the primary caregiver, collaboratively establishes and regularly reviews the POC.

Services Included in Medicare Part A Hospice Benefits

The Medicare hospice benefit is comprehensive, covering a wide range of items and services designed to alleviate pain, manage symptoms, and provide holistic support for patients and their families. These services are all aimed at addressing the terminal illness and related conditions. Key services include:

• Physician Services: Care from hospice-employed physicians, nurse practitioners, and the patient’s chosen attending physician, all coordinated within the hospice framework.
• Nursing Care: Skilled nursing care, essential for managing medical needs and ensuring patient comfort.
• Medical Equipment: Provision of necessary medical equipment, such as hospital beds, wheelchairs, and oxygen equipment, to enhance comfort and care at home.
• Medical Supplies: All required medical supplies related to the terminal illness, including bandages, catheters, and other necessary items.
• Medications for Pain and Symptom Management: Drugs specifically aimed at controlling pain and managing symptoms associated with the terminal illness.
• Hospice Aide and Homemaker Services: Assistance with personal care and everyday tasks provided by hospice aides and homemakers, offering support to both patients and families.
• Therapy Services: Physical therapy, occupational therapy, and speech-language pathology services to help patients maintain function and independence as long as possible.
• Medical Social Services: Support from medical social workers to address emotional, social, and practical needs of patients and their families.
• Dietary Counseling: Nutritional advice and counseling tailored to the patient’s needs and condition.
• Spiritual Counseling: Spiritual support and counseling services to address the spiritual and emotional concerns of patients and families.
• Grief and Loss Counseling: Individual and family counseling, both before and after the patient’s death, to help cope with grief and loss.
• Short-Term Inpatient Care: Inpatient care for pain control and symptom management that cannot be effectively managed at home, as well as respite care for caregivers.

In addition to these core services, Medicare may cover other services deemed reasonable and necessary within the patient’s plan of care. The hospice program is responsible for offering and arranging these additional services as needed.

Levels of Hospice Care Under Medicare Part A

Medicare utilizes a daily rate payment system for hospice agencies, regardless of the number of services provided on any given day. These daily rates are categorized into four levels of care, reflecting the intensity of services required by the patient:

1. Routine Home Care: This is the most common level of care, provided when a patient chooses to receive hospice care at home (which can be their house, a skilled nursing facility, or an assisted living facility) and is not in a crisis situation requiring continuous care.
2. Continuous Home Care: This level is for patients experiencing a brief period of crisis and requires intensive care at home. It involves care primarily consisting of continuous nursing care at home, along with hospice aide and homemaker services, as needed to maintain the patient at home and avoid inpatient admission.
3. Inpatient Respite Care: This offers temporary inpatient care in an approved facility for up to 5 consecutive days. Respite care is designed to provide a break for the patient’s caregiver, allowing them temporary relief from caregiving responsibilities.
4. General Inpatient Care: This level is for managing pain control or acute or chronic symptom management that cannot be effectively managed in other settings, requiring a short-term stay in an inpatient facility such as a hospital or hospice inpatient unit.

Understanding Hospice Coinsurance with Medicare Part A

While Medicare Part A covers the majority of hospice care costs, patients may be responsible for certain coinsurance amounts:

• Drugs and Biologicals Coinsurance: For prescription drugs and biologicals used for pain and symptom management during routine home care or continuous home care, patients are typically responsible for a coinsurance of 5% of the cost of the medication to the hospice. However, this coinsurance is capped at a maximum of $5.00 per prescription. There is no coinsurance for medications during general inpatient care or respite care.
• Respite Care Coinsurance: For inpatient respite care, patients may be charged a coinsurance of 5% of the Medicare payment for each respite care day. This coinsurance amount cannot exceed the current inpatient hospital deductible for the year in which the hospice care period began. This coinsurance covers room and board costs during respite care.

Hospice Quality Reporting Program

Medicare is committed to ensuring high-quality hospice care. The Hospice Quality Reporting Program collects and reports data on the quality of care provided by hospice agencies. This program aims to improve transparency and accountability in hospice care, helping patients and families make informed decisions when choosing a hospice provider. Further details about quality data submission and reporting requirements can be found on the [Current Measures]([invalid URL removed]) and [Hospice Quality Reporting]([invalid URL removed]) webpages.

By understanding the benefits of hospice care under Medicare Part A, individuals facing terminal illness can access compassionate and comprehensive support, focusing on comfort and quality of life during their final months.