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It can be difficult trying to set up end-of-life care for a loved one. Understanding their Original Medicare hospice benefit is a significant part of the process because hospice care can be costly. It can get confusing trying to figure out all the qualifications, coverage, and specific rules, especially when you’re dealing with something as emotionally and mentally challenging as hospice. We’re here to help with five things you should know about Medicare and hospice.

1. Who Qualifies for Hospice?

Hospice care is specifically designed to provide comfortable end-of-life care for patients with terminal illnesses. It’s important to know exactly who qualifies for the Medicare hospice benefit, so you know when you can place your loved one in care. Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance). To receive the Medicare hospice benefit under Part A, the following conditions must be met:

  • The patient has been diagnosed with a terminal illness by their primary care provider or hospice doctor that includes a prognosis of six months or less.
  • The patient accepts palliative care as opposed to treatment to cure their terminal illness and signs a statement to that effect. While making the decision to enter hospice care is permanent for most patients, it’s possible for the patient to opt out of care and seek treatment to cure their illness.

2. Medical Conditions That Qualify for Hospice

About half of all hospice patients have a cancer diagnosis, but there are many other medical conditions and diseases that qualify for hospice care as well, including:

  • Liver disease
  • Stroke
  • AIDS
  • Congestive heart failure
  • Diabetes
  • Heart valve disorders
  • End-Stage Renal Disease
  • Parkinson’s Disease
  • Huntington’s Disease
  • Multiple Sclerosis
  • Dementia

If your loved one has a terminal illness that’s not included on the list above and has a prognosis of less than six months, check with their medical provider about the possibility of hospice care.

3. What Medicare Will Pay for During Hospice

Get the most out of your loved one’s Medicare hospice benefit and make sure it’s covering as many of the associated costs as possible. Fortunately, Medicare’s hospice coverage is extensive and it’s likely you’ll be left with relatively little out-of-pocket expenses after care is complete. You’ll find that Medicare covers items and services like:

  • Doctor services
  • Nursing care
  • Prescription medications
  • Dietary counseling
  • Medical equipment (wheelchairs, walkers)
  • Medical supplies (bandages, catheters)
  • Hospice aides
  • Homemaker services
  • Physical therapy/occupational therapy
  • Speech-language pathology
  • Social worker services
  • Grief and loss counseling for patient/family
  • Short-term inpatient care (pain/symptom management)
  • Short-term respite care • Other services to manage your symptoms as determined by your hospice team

4. What Medicare Won’t Pay for During Hospice

It’s important to remember that when a family decides it’s time for care or the patient agrees to go into hospice care, there’s an agreement that there won’t be any further treatment intended to cure the terminal illness. This is a big part of what will disqualify treatment from Medicare hospice benefits. Other services and treatments that won’t be covered by Medicare include:

  • Room and board if the patient receives care in their home, lives in a nursing home or a hospice inpatient facility. Medicare will only pay for care in a facility if the hospice team determines they need short-term inpatient or respite care.
  • Treatment or medications intended to cure the illness and/or related conditions.
  • Care from a provider not set up by the patient’s hospice team.
  • Outpatient care, inpatient care or ambulance care that wasn’t arranged by the hospice team.

If you’re seeking care or treatment for a loved one in hospice care, work directly with their hospice team so it’s arranged by them. Working with the hospice team will ensure necessary treatment is prescribed and will improve the chances of having care covered by Original Medicare. A Wellcare Medicare Advantage plan can offer services above and beyond what Original Medicare will cover for a patient in hospice care. Contact us today for to explore your options.

5. How Long Can a Person Be in Hospice?

Hospice care isn’t meant to last longer than six months. The six-month care period is broken into two 90-day benefit periods with Medicare and the patient’s primary hospice doctor or primary doctor needs to recertify that they’re terminally ill. However, should a patient outlive their original prognosis of six months, they can continue in hospice care as needed. The patient can receive care in unlimited 60-day benefit periods if their doctor recertifying terminal illness at the end of each period. You can help your loved one get the care they need as they reach the end of life with a terminal illness by ensuring they’re covered by Medicare. Work closely with their primary doctor and hospice team to get the most benefits available through their Medicare plan.

Frequently Asked Questions

Does Medicare pay if the patient is in hospice?

Yes, Medicare includes a hospice benefit. Medicare will only pay for care while the patient is in hospice if medications and treatment aren’t meant to cure the illness and/or related conditions.

What excludes a patient from hospice under Medicare?

A patient cannot be admitted into hospice care if they don’t have a terminal illness with a prognosis of six months or less to live.

How do you know when hospice is needed?

Primarily, a patient needs hospice when they have a terminal illness and receive a prognosis of six months or less to live. Additionally, patients can receive hospice care as their condition progresses, which is measured by an inability to perform normal activities and significant weight loss.

How long does hospice usually last?

Hospice is meant to least six months at the most, but a patient’s doctor can recertify as terminally ill if they live longer than their original prognosis and continue to receive care.

Which Medicare Advantage Plan is right for you?

Call us today to learn more and enroll.

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Sources - Hospice Care - How Hospice Works
Centers for Medicare & Medicaid Services - Medicare Hospice Benefits

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Y0020_WCM_134133E_M Last Updated On: 3/7/2024