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Fast Fact and Concept #82: Medicare Hospice Benefit Part I: Eligibility and Treatment Plan

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Title: Fast Fact and Concept #82: Medicare Hospice Benefit Part I: Eligibility and Treatment Plan

Author(s): Robin Turner, MD

In the United States, the Medicare Hospice Benefit (MHB) pays for 80% of all hospice care. Established in 1983, the MHB pays for medical, nursing, counseling and bereavement services to terminally ill patients and their families. The original goal of the MHB was to support families caring for their dying relative at home. Under certain circumstances, hospice services under the MHB can also be provided in a nursing home or the acute care hospital. Referral for hospice care is appropriate when the overall plan of care is directed toward comfort rather than reversing the underlying disease process.

Eligibility-Medicare Hospice Benefit

  1. The patient must be entitled to Medicare Part A (hospital payments); once the patient decides to enter hospice care, they sign off Part A and sign on (elect) the MHB. Note: this process is reversible-patients may at a future time elect to return to Medicare Part A.
  2. The patient must be certified by the Hospice Medical Director and 1 physician to have a life expectancy < 6 months "if the patient's disease runs its natural course". Patients can continue to be eligible if they live beyond 6 months as long as the physicians believe death is likely within 6 months.
  3. Under Medicare, DNR status cannot be used as a requirement for admission.

Covered Services (100% coverage with no co-pay)

  1. Case oversight by the physician Hospice Medical Director
  2. Nursing Care: symptom assessment, skilled services/treatments and case management. The nurse visits routinely; 24-hour/7-day per week emergency contact is also provided.
  3. Social Work: counseling and planning (living will, DPOA)
  4. Counseling Services including chaplaincy
  5. All medications and supplies related to the terminal illness. . The hospice may charge a $5 copay per medication, but most choose not to charge this. Medications for conditions not related to the terminal condition are not covered
  6. Durable medical equipment: hospital bed, commode, wheelchair, etc.
  7. Home Health Aid and Homemaker Services.
  8. Speech therapy, Nutrition, PT, and OT services as determined by the POC (see below)
  9. Bereavement support to family after the death
  10. Short term General Inpatient Care for problems that cannot be managed at home-most commonly intractable pain, delirium, or caregiver breakdown
  11. Short term Respite Care-up to 5 days to permit family caregivers to take a break
  12. Continuous care at home for short episodes of acute need

Not Covered

Plan of Care (POC)
The hospice team and the patient's physician work together to maximize quality of life by jointly developing the Plan of Care. The POC is based on the patient's diagnosis, symptoms and other needs. The hospice program and the patient's physician must together approve any proposed tests, treatments and services. In general, only those treatments that are necessary for palliation and/or management of the terminal illness will be approved.

Physician Role
At the time of enrollment the patient indicates the primary physician who will direct care; the patient may select a hospice physician for this role or may select their usual primary doctor. The primary physician is responsible for working with the hospice team to determine appropriate care.

Also see:
Fast Fact #87, Medicare Hospice Benefit Part II: Places of Care and Funding
Fast Fact #90, Medicare Hospice Benefit Part III: Special Interventions

References:

Centers for Medicare & Medicaid Services. Hospice Manual Chapter II-Coverage of Services.[Online] Available http://cms.hhs.gov/manuals/21_hospice/hs200.asp. October 11, 2002.

Gretchen M. Brown, Connie A. Raffa, JD, LLM & Susan Swinford, BSW, MSW. How to Fund Your Palliative Care Program Concurrent Session D Part 1.PowerPoint Presentation. [Online] Available http://www.capcmssm.org/content/203/index/html. October 21, 2002.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #82 . Medicare Hospice Benefit Part 1. Turner, R. January 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: System-based Practice

Keyword(s): Caring for families, Home care benefit, Medicare hospice benefit, Post-death family care, Quality of life, Spirituality


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).