Hospice Care & Medicare

I recently got a call from someone asking how Hospice care works when you're on Medicare.  Here is what I discovered...

According to the Medicare.gov website, if you qualify for hospice care, you’ll have a specially trained team and support staff available to help you and your family cope with your illness. Your doctor and the hospice team will work with you and your family to set up a plan of care that meets your needs.

Your plan of care includes hospice services that Medicare covers. For more specific information on a hospice plan of care, call the Maine Hospice Council & Center for End of Life Care 1-800-438-5963 or visit http://mainehospicecouncil.org/hospice-programs-in-maine/ for a list of programs in Maine.

The hospice program you choose must be Medicare-approved to get Medicare payment. To find out if a certain hospice program is Medicare-approved, ask your doctor, the hospice program, your state hospice organization, or your state health department.

Can I get hospice care in my own home?Elderly couple embracing

Yes!  Medicare also states that most hospice patients get hospice care in the comfort of their home and with their families.  Depending on your condition, you may also get hospice care in a Medicare-approved hospice facility, hospital, nursing home, or other long-term care facility.  The hospice benefit with Medicare allows you and your family to stay together in the comfort of your home unless you need care in an inpatient facility. If the hospice team determines that you need inpatient care, the hospice team will make the arrangements for your stay.

  • Hospice care is intended for people with 6 months or less to live if the disease runs its normal course.  
  • You can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods.  
  • A benefit period starts the day you begin to get hospice care and it ends when your 90-day or 60-day period ends.  
  • You have the right to change providers only once during each benefit period
  • At the start of each period, the hospice medical director or other hospice doctor must re-certify that you’re terminally ill, so you can continue to get hospice care.
  • If you live longer than 6 months, you can still get hospice care, as long as the hospice medical director or other hospice doctor re-certifies that you're terminally ill.

Also all Medicare-covered services you get while in hospice care are covered under Original Medicare, even if you're in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan. That includes any Medicare-covered services for conditions unrelated to your terminal illness or provided by your attending doctor.

What happens if I need other medical services?

Once you choose hospice care, Medicare will no longer cover treatment intended to cure your terminal illness so talk with your doctor if you're thinking about getting treatment to cure your illness. Prescription drugs to cure your illness (rather than for symptom control or pain relief) also will no longer be covered by Medicare.  But remember, you always have the right to stop hospice care at any time for any reason. If you stop your hospice care, you'll get the type of Medicare coverage you had before you chose a hospice program (like treatment to cure the terminal illness) If you're eligible, you can go back to hospice care at any time as well.

All care that you get for your terminal illness must be given by or arranged by the hospice team. You can't get the same type of hospice care from a different provider, unless you change your hospice provider. However, you can still see your regular doctor if you've chosen him or her to be the attending medical professional who helps supervise your hospice care.

Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.

Care in an emergency room, inpatient facility care, or ambulance transportation is also not covered, unless it's either arranged by your hospice team or is unrelated to your terminal illness.  This means you MUST contact your hospice team before you get any of these services or you might have to pay the entire cost.

What are the costs for Hospice Care under Original Medicare?Elderly woman kissing young girl

  • $0 for hospice care and there is no deductible.
  • Co-payment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management.
  • 5% of the Medicare-approved amount for inpatient respite care (short-term care given by another caregiver, so the usual caregiver can rest).
  • Your usual Part B deductible and coinsurance for your doctor’s services (if your attending doctor isn't employed by the hospice).
  • Medicare doesn't cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).
  • If you pay out-of-pocket for an item or service your doctor ordered, but the hospice refuses to give you, you can file a claim with Medicare. If your claim is denied, you may file an appeal.

Please Contact Me if you have any questions.