Is Hospice Covered by Medicare?

The Rules for Hospice and Medicare in New Jersey

The government health-insurance program can help pay for comfort-care toward the end of life.

is hospice covered by medicareIf you or a loved one are on Medicare, you probably know it covers many medical services. Depending on the type of Medicare plan you’ve chosen, the program can help pay for your doctor visits, hospitalizations, prescription drugs and more.

But what if you are terminally ill, and you no longer want aggressive treatment? How will you maintain your comfort and dignity -- and perhaps even remain at home for your last weeks and months?

That’s where hospice comes in. Hospice is a special kind of care for people near the end of life, which focuses on enhancing comfort and quality of life, rather than attempting to cure a person's illness.

Many people agree that hospice seems like a good choice for themselves of their loved one. But, the big questions become: can I afford the care? Is hospice care covered by Medicare?

For many people, the answer is “yes.” Medicare has certain rules about who qualifies for coverage of hospice care, which are explained below.

What is hospice?

Hospice is a holistic form of care that addresses one’s physical, emotional, social, and spiritual needs, as defined by the patient and family. It enables people to spend time focusing on what matters most to them, and often allows them to avoid hospitalization at the end of life.

Care is given where the patient lives, such as the family’s home, assisted- living facility or nursing home. Patients who need intensive, 24-hour support to relieve pain or other symptoms can receive care in specialized, inpatient hospice centers. 

Hospice provides benefits to the family, too, including advice and support on caring for their loved one, on-call access to the hospice team, respites from caregiving, and grief support.

Care is provided by a specially trained team, including hospice physicians, nurses, certified home health aides, social workers, spiritual support counselors, grief counselors, various types of therapists, and trained volunteers. Services can include physical care, counseling, prescription drugs, equipment, and supplies for the person’s illness and related conditions. For more details on hospice services covered by Medicare, see the list below.

When Is hospice covered by Medicare?

is hospice covered by medicareMedicare will pay for hospice care for patients who have Medicare Part A (Hospital Insurance) or Part C (Medicare Advantage Plans) and meet the following conditions:
 
• Your regular doctor and the hospice medical director certify that you have a life expectancy of six months or less.
• You accept hospice care instead of care to cure your terminal illness.
• You sign a statement choosing hospice care instead of other Medicare-covered benefits to treat your terminal illness and related conditions.

In addition, the hospice provider you choose must be Medicare-approved, in order to receive Medicare coverage for hospice care.

Medicare covers hospice care for specific time periods. It pays for two consecutive 90- day periods, followed by an unlimited number of 60-day periods. At the start of each period, the hospice medical director and your doctor must recertify that you’re terminally ill (with a life expectancy of six months or less), so you can continue to receive hospice care. You have the right to change hospice providers once during each benefit period.

If you’re not sure what type of Medicare coverage you have, here are ways to find out:

• Check your red, white, and blue Medicare card.
• Check any other insurance cards you use. Call the phone number on each card to get more information about your coverage.
• Check your Medicare health or drug plan enrollment. You can click on this link and sign in (or create an account) to access your enrollment information.
• Call 1-800-MEDICARE (1-800-633-4227). 

What hospice services does Medicare cover?

is hospice covered by medicareThe Medicare hospice benefit generally covers everything needed by a terminally ill person and their family. It provides:

• Comprehensive care and support to addresses physical, emotional, social, and spiritual needs.
• Palliative (comfort) care for relief from pain and other distressing symptoms.
• Consultation by the hospice medical director.
• Services in the home or any home-like setting, including nursing homes and assisted living communities.
• A team approach by the hospice staff and your own physician.
• Bereavement counseling and support for family caregivers for 13 months following the loss of a loved one.

Depending on your terminal illness and related conditions, your hospice team will create a plan of care that can include:
 
• physician services
• nursing care
• medical equipment, such as wheelchairs, walkers, and supplemental oxygen
• medical supplies, such as wound dressings, catheters and incontinence supplies
• prescription drugs
• hospice aide and homemaker services
• physical, occupational and speech-language therapies
• social worker services
• pastoral counseling and chaplain services
• dietary counseling
• grief and loss counseling for the patient and family
• short-term inpatient care for pain and symptom management
• short-term respite care (see next paragraph)
• any other Medicare-covered services needed to manage your pain and other symptoms that are part of your terminal illness and related conditions, as recommended by your hospice team.

If your usual caregiver (such as a family member) needs a break from caregiving, you can receive inpatient respite care in a Medicare-approved facility. The facility can be an inpatient hospice center, hospital, or nursing home. Your hospice provider will make these arrangements if you request them.

If you have any health problems that are not part of your terminal illness or related conditions, Original Medicare will still pay for covered hospice benefits for such needs. However, this situation is rare. 

What if I change my mind about hospice care?

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 started hospice – such as treatment to cure the terminal illness.

You can return to hospice care at any time, as long as you meet the eligibility requirements described above. 

What do I pay out-of-pocket for hospice care?

end-stage dementiaIf you’re covered by Medicare’s hospice benefit, you will only pay a small portion of the costs of your care. According to Medicare, you are only responsible for:
 
• A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management. In the rare case your drug isn’t covered by the Medicare hospice benefit, your hospice provider should contact your Medicare drug plan (if you have one) to see if it’s covered under Medicare prescription drug coverage (Part D).

• 5% of the Medicare-approved amount for inpatient respite care. All Medicare-covered services you receive while on hospice care are covered under Original Medicare, even if you were previously in a Medicare Advantage Plan (such as an HMO or PPO) or other Medicare health plan.

Also, if your Medicare Advantage Plan or other Medicare health plan covers extra services that Original Medicare doesn’t cover (such as dental and vision benefits), your plan will continue to cover these extra services while you’re on hospice care (as long as you continue to pay your premium).

What are my rights under Medicare?

People who are on Medicare have certain guaranteed rights. For instance, if you are told you no longer qualify for hospice care because your condition has improved—but you disagree—you can ask Medicare to review your case

  • Your hospice provider is required to give you a notice that explains your right to an expedited (fast) review by an independent reviewer contracted by Medicare, called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). If you don’t receive this notice, make sure to ask for it. The notice provides your BFCC- QIO’s contact information and explains your rights.
  • You can also visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your BFCC-QIO. TTY users should call 1-877-486-2048.
  • In addition, if you pay out-of-pocket for an item or service your doctor ordered, but your hospice provider refuses to give it to you, you can file a claim with Medicare. If your claim is denied, you can file an appeal.
  • For more information on appeals, visit Medicare.gov/appeals or call 1-800-MEDICARE.

For more information

Here are some additional resources to learn more about Medicare and paying for hospice:

  • To learn more about Medicare eligibility, coverage, and costs, visit Medicare.gov or call 1-800-MEDICARE.
  • For free health insurance counseling and personalized help with insurance questions, contact your State Health Insurance Assistance Program (SHIP).
  • For New Jersey residents, visit  http://www.state.nj.us/humanservices/doas/services/ship/index.html or call 1-800-792-8820 (in state only) or 1-877-222-3737 (out of state).
  • For residents of other states, visit shiptacenter.org or call 1-800- MEDICARE to find the contact information for your state’s SHIP.

For more information about hospice, contact:

  •  National Hospice and Palliative Care Organization: Visit nhpco.org or call 707-837-1500
  • Home Care & Hospice Association of New Jersey: http://www.homecarenj.org
  • Hospice Association of America: Visit nahc.org/haa or call 202-546-4759
  • Samaritan Healthcare & Hospice (800) 229-8183

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About Medicare

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, known as ESRD). Different parts of Medicare cover different services, and you can choose which parts to enroll in:

  • Part A (hospital insurance) covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
  • Part B (medical insurance) covers certain doctors' services, outpatient care, medical supplies, and preventive services.
  • Part C (Medicare Advantage Plans) consists of plans offered by private companies that contract with Medicare to provide you with all your Part A and Part B benefits. Some also offer prescription drug coverage.
  • Part D (prescription drug coverage) adds prescription drug coverage to Original Medicare
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