- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 2: Medicare Basics
The Hospice Benefit
Table of Contents
- The Hospice Benefit
- Requirements for Coverage
- Hospice Benefit Days and Costs
- Hospice Services
- Noncovered Hospice Services
The Hospice Benefit
Hospice is a special Medicare benefit for beneficiaries that have a terminal illness and are certified by their physician to be within the last six months of their lives. The goal of the hospice benefit is not to cure the beneficiary’s illness but to provide physical care, pain management, and counseling to help the beneficiary cope with his/her illness.
When a beneficiary chooses the hospice benefit, they also choose a hospice agency to administer their hospice services. Hospice agencies are organizations certified by CMS to manage all of the medical needs of the beneficiary involving their terminal illness. The hospice agency makes available a network of providers including physicians, nurses, aids, counselors, therapists and support personnel.
In choosing the hospice benefit, the beneficiary relinquishes the traditional Medicare benefit in lieu of a total care plan administered by a hospice agency. This means that once a beneficiary chooses the hospice benefit, all services that they receive related to the hospice condition are organized by the hospice agency.
It is important to note that when a beneficiary chooses the hospice benefit, he/she is only relinquishing the traditional Medicare benefit for services related to their hospice condition. The beneficiary still is enrolled in the Medicare program and the traditional Medicare benefit is in effect for any services that the beneficiary requires that are not related to his/her hospice condition.
For example, a beneficiary who has a hospice condition of lung cancer can still receive emergency room services for a broken ankle. The emergency room services would be paid for under the traditional Medicare benefit, while any services related to the lung cancer diagnosis would be paid for under the Hospice benefit. If the services are unrelated to hospice, providers should add condition code 07 to the claim and submit the claim to National Government Services.
Requirements for Coverage
To be eligible for hospice care, a beneficiary must meet all of the following five qualifications:
- The patient is enrolled in Medicare Part A;
- The patient’s doctor certifies that he/she is terminally ill and probably has less than six months to live;
- The hospice medical director certifies that he/she is terminally ill and probably has less than six months to live;
- The patient signs a statement choosing hospice care instead of traditional Medicare-covered benefits for his/her terminal illness;
- The patient receives care from a Medicare-approved hospice program.
Hospice Benefit Days and Costs
The hospice benefit is administered in periods of care. Covered periods of care are two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period of care, the beneficiary’s doctor must certify that he/she is terminally ill and probably has less than six months to live. Even if the beneficiary lives longer than six months, hospice care will continue to be covered as long as the beneficiary’s doctor recertifies that the beneficiary has a terminal illness. The only costs to the patient are:
- No more than $5 for each prescription drug or similar product for pain relief and symptom control
- Five percent (5%) of the Medicare payment amount for inpatient respite care
Hospice Services
The hospice benefit is an expanded benefit under Medicare. That is, many services that are normally not covered under traditional Medicare may be covered under the hospice benefit.
- Covered services under the hospice benefit are:
- Physician services (on-call 24 hours a day, seven days per week)
- Nursing care (on-call 24 hours a day, seven days per week)
- Durable Medical Equipment, such as wheelchairs or walkers
- Medical supplies, such as bandages and catheters
- Medications for symptom control and pain relief
- Short-term care in a hospital, including respite care
- Home health aide and homemaker services
- Physical and occupational therapy
- Speech-language pathology
- Social worker services
- Dietary counseling
- Grief and loss counseling for the beneficiary and their family members
Depending on the beneficiary’s illness and condition, services can be provided in the beneficiary’s home, a hospice facility, a hospital, or a nursing home.
When a patient is receiving hospice services primarily in his/her home, members of the hospice team will make regular visits, but the burden of around-the-clock care is usually on a family member. To ease the strain on the caregiver, the hospice benefit includes inpatient respite care for the beneficiary. The respite care benefit is an inpatient stay of up to five days in a Medicare-approved hospital or SNF. A beneficiary is entitled to an unlimited number of respite care stays.
Noncovered Hospice Services
Noncovered services under the hospice benefit include:
- Treatment to cure the terminal illness
- Care from another hospice that was not set up by the chosen hospice
- Care from another provider that is the same care that the chosen hospice provides
Revised 1/2021