Items and Services included in the Hospice Benefit
Hospice Coverage Explained for Medical Providers
Hospice is a comprehensive, holistic program of care and support for terminally ill patients and their families. Hospice care focuses on comfort care for symptom management and pain relief instead of curative care.
Patients with Medicare Part A can get hospice care benefits if they meet the following criteria:
- They get care from a Medicare-certified hospice.
- Their physician and the hospice physician certify them as terminally ill, with a medical prognosis of 6 months or less to live if the illness runs its normal course.
- They sign an election statement to elect the hospice benefit and waive all rights to Medicare payments for terminal illness and related conditions.
After certification, the patient may elect the hospice benefit for:
- Two 90-day periods followed by an unlimited number of subsequent 60-day periods.
- After the second 90-day period, the recertification associated with a hospice patient’s third benefit period, and every subsequent recertification, must include documentation that a hospice physician or a hospice nurse practitioner had a face-to-face (FTF) encounter with the patient. The FTF encounter must document the clinical findings supporting a life expectancy of 6 months or less.
All hospice care services offered to patients and their families must follow an individualized written plan of care (POC) that meets the patient’s needs. The interdisciplinary hospice team establishes the POC with the attending physician, the patient or representative, and the primary caregiver.
Items and services included in the hospice benefit
The Medicare hospice benefit includes these items and services to reduce pain or disease severity and manage terminal illness and related conditions:
- Services from a hospice-employed physician, nurse practitioner (NP), or other physicians chosen by the patient
- Nursing care
- Medical equipment
- Medical supplies
- Drugs to manage pain and symptoms
- Hospice aide services
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Dietary counseling
- Spiritual counseling
- Grief and loss counseling before and after the patient’s death
- Short-term inpatient pain control and symptom management, as well as respite care
Services not covered in the Hospice Benefit
All services included in the management of terminal illness must be provided by or through the hospice. When a Medicare beneficiary chooses hospice care, Medicare will not pay for the following:
- Active treatment of terminal illness that is not for symptom management and pain control.
- Care provided by another hospice that was not arranged by the patient’s hospice.
- Care from another provider that duplicates care the hospice is required to furnish.
Hospice Levels of Care
Generally, Medicare pays hospice agencies a daily rate for each day a patient is enrolled in the hospice benefit. Medicare makes this daily payment regardless of the number of services provided on a given day, including when the hospice provides no services. The daily payment rates cover the hospice’s costs for providing services included in patient care plans. Medicare makes daily payments based on 1 of 4 levels of hospice care:
1. Routine home care: The patient elects to get hospice care at home and isn’t getting continuous home care. A patient’s home might be a home, a skilled nursing facility (SNF), or an assisted living facility. Routine home care is the level of care provided when the patient isn’t in crisis.
2. Continuous home care: Eligible patients receive nursing care for at least 8 hours continuously and up to 24 hours in the day for the management of acute medical symptoms and when both of these apply:
The patient gets hospice care in a home setting that isn’t an inpatient facility (hospital, SNF, or hospice inpatient unit)
The care consists mainly of nursing care continuously at home. Patients can also get hospice aid continuously. Hospice patients can get continuous home care only during brief periods of crisis and only as needed to maintain the patient at home.
3. Inpatient respite care: The patient elects to get hospice care in an approved inpatient facility for up to 5 consecutive days to give their caregiver a rest.
4. General inpatient care: The patient elects hospice care in an inpatient facility for pain control or acute or chronic symptom management, which can’t be managed in other settings.