Understanding the Medicare Hospice Benefit

In 1982, Congress established the Medicare Hospice Benefit. To receive Medicare reimbursement, hospice agencies must comply with Medicare conditions of participation. State and Federal regulations and conditions of participation define eligibility requirements for beneficiaries, required services, levels of care, and reimbursement guidelines.

Eligibility Requirements

A patient must be eligible for Medicare Part A

Two physicians, usually the patient’s attending physician and the hospice physician, must certify that the patient has a "medical prognosis that his or her life expectancy is six months or less, if the illness runs its normal course"

The patient must agree to palliative rather than curative care and to surrender all other Medicare benefits related to the terminal prognosis (Professional services of the patient’s attending physician continue to be covered)

At defined intervals, per the hospice regulations and guidelines, the Hospice physician must certify that the patient's prognosis continues to be six months or less from the date of the most recent certification

Services

All medications and necessary supplies related to the patient's terminal diagnosis (including medications for palliation – e.g. pain, nausea/vomiting)

Medical equipment and supplies related to the patient’s terminal diagnosis

A Registered Nurse Case manager to supervise the Plan of Care, provide direct care and instruct the patient and family / caregiver

Certified Hospice Aides to assist the patient with Activities of Daily Living and personal care

Physician services to assist in the palliation of the terminal illness and related conditions

Spiritual Care Services to meet the unique spiritual needs and desires of the patient

Social workers who focus on financial, emotional and psychosocial issues

Volunteers who provide companionship and supportive visits for the patient and family

As indicated for Palliative purposes, physical, occupational and speech therapy, and dietary counseling

As indicated for Palliative purposes, laboratory and diagnostic procedures

Reimbursement

Hospice agencies are paid a daily per-diem rate. This per-diem rate covers all services, equipment, and supplies as defined previously, as they relate to the patient’s terminal diagnosis

The per-diem reimbursement varies based on the level of care the patient is receiving

The patient's attending physician may continue to bill Medicare Part B for professional services provided the physician is not a paid employee of the hospice

The Medicare Hospice Benefit is an inclusive benefit. All products and services are provided by the elected Hospice or their contracted providers

Care and services not related to the patient’s terminal diagnosis continue to be covered by Medicare Parts A and B with all applicable rules