Hospice is a program of end-of-life pain management and comfort care for those with a terminal illness. In this blog about Medicare-covered hospice, we write directly to patients as if they are the ones taking these actions or making these decisions. However, discussions about hospice often involve caregivers and family members as well. If you are a caregiver, family member, or a patient’s appointed representative, you may be leading these conversations or decisions, rather than the patient.
First, let’s understand how the Medicare hospice benefit works.
Medicare’s hospice benefit is primarily home-based and offers end-of-life palliative treatment. Palliative treatment provides pain management services, rather than curative care. The goal of hospice is to help you be as comfortable as possible, not to cure an illness. Services covered under the hospice benefit include skilled nursing and skilled therapy services, hospice aides and limited homemaker services, medical supplies, durable medical equipment, respite care, short-term inpatient care, and other services. Hospice coverage also includes any prescription drugs needed for pain and symptom management related to the terminal condition, while a Part D plan may cover medications that are unrelated to your terminal condition. To elect hospice:
1. You must be enrolled in Medicare Part A.
2. You must have a doctor certify that you have a terminal illness, meaning a life expectancy of six months or less. (Note that another kind of health care provider, such as a nurse or physician’s assistant, cannot certify that you have a terminal illness for Medicare coverage of hospice.)
3. You or your appointed representative must sign a statement electing to have Medicare pay for palliative care, rather than curative care.
4. You must receive care from a Medicare-certified hospice agency.
Once you choose hospice, your hospice-related services are almost always covered under Original Medicare. If you have a Medicare Advantage Plan, it continues to pay for any care that is unrelated to your terminal condition. Note that some Medicare Advantage Plans participate in a special demonstration program to cover hospice care. If your plan participates in this program, then it will cover your hospice care instead of Original Medicare.
Hospice generally takes place at home, with your hospice provider sending aides, nurses, and/or skilled therapists to provide the pain management services in your place of residence, which might be a facility, like a nursing home, if that is where you normally reside. Hospice can sometimes take place at an inpatient facility if your hospice provider determines inpatient care is necessary for you. If your hospice provider determines that you need inpatient care, they must be the one to make the arrangements. The cost of your inpatient stay is covered by the hospice benefit, but if you go to the hospital for hospice care and your hospice provider didn’t make the arrangements, you might be responsible for the full cost of the stay.
If you have any questions about the hospice benefit, contact your local State Health Insurance Assistance Program (SHIP). Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
Now that we understand hospice, let’s make sure we know how to elect the hospice benefit and begin receiving care.
If you are interested in Medicare’s hospice benefit, ask your health care provider whether you meet the eligibility criteria for Medicare-covered hospice care. If so, they can contact a Medicare-certified hospice on your behalf. There may be several Medicare-certified hospice agencies in your area. If the first one you, your caregiver, or your provider contact is unable to help you, contact another. Once you have found a Medicare-certified hospice, the hospice medical director and your regular doctor, if you have one, will certify that you are eligible for hospice care. Afterward, you must sign a statement electing hospice care and waiving curative treatments for your terminal illness. Your hospice team must consult you—and your primary care provider if you wish—to develop a plan of care. Your team may include a hospice doctor, a registered nurse, a social worker, and a counselor. Medicare covers hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods. A doctor’s certification is necessary for each benefit period.
If you would like to begin receiving curative treatment again, it is important to know how to end the hospice benefit.
If you decide you want curative treatment, you have the right to stop hospice at any time. Speak with your hospice doctor if you are interested in stopping. If you end your hospice care, you will be asked to sign a form that includes the date such care will end. Afterward, you will again receive Medicare the way you did before choosing hospice, either through Original Medicare or a Medicare Advantage Plan. If you choose to end hospice care, make sure you provide your Part D plan with written proof of the change so that it can update your status in its system. You can elect hospice again later if you continue to meet the eligibility requirements.
Finally, be on the lookout for potential hospice fraud, errors, or abuse.
Hospice fraud occurs when Medicare is falsely billed for any level of hospice care or service. Scammers can get beneficiaries to agree to hospice even though they do not qualify for the benefit. As a Medicare beneficiary, you should look out for suspicious behavior from health care providers that might indicate Medicare fraud or abuse. Report potential hospice fraud, errors, or abuse if:
You have been falsely certified as being terminally ill
You were enrolled in hospice without you or your family’s permission
You find out someone is falsely certifying or failing to obtain physician certification on plans of care
You were offered gifts or incentives to receive hospice services or to refer others for hospice services
You see on your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) that you were billed for a higher level of care than was needed or provided, or for services not received
You experience high-pressure and unsolicited marketing tactics of hospice services
You know a hospice beneficiary being abused or neglected by a hospice worker
If you suspect that a provider is committing potential hospice care fraud, you should contact your local Senior Medicare Patrol (SMP). Your SMP can help you identify potential fraud, errors, and abuse, and report your concerns.
You can stop hospice fraud by following a few guidelines.
First, be sure your doctor has assessed your condition and certified that you are terminally ill.
Second, be wary of deals that seem too good to be true. For example, never accept gifts in return for hospice care.
Third, report any potential fraudulent, erroneous, or abusive hospice care to your local Senior Medicare Patrol (SMP).
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any other Medicare-related questions or concerns you have. SHIP counselors are government-funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.