Care for the Elderly and the Terminally Ill: What Services Does Medicare Cover?

In 2021, 1,7 million Americans have chosen hospice services that provide comfort, care, and support to those nearing the end of life. But many people wonder, does Medicare cover hospice services? In short, yes. Edition Fortune tell what services the insurance pays for.

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To receive hospice care, a patient must meet these three conditions:

• have an incurable diagnosis by a hospice doctor and another doctor (often the referring doctor) who must confirm that the patient's life expectancy is a maximum of six months;
• the patient must agree to accept comfort care (known as palliative care) instead of medical care to treat the illness;
• the patient must sign a statement choosing hospice treatment over other treatments for a terminal illness and related health problems, although this document can be revoked at any time by the patient or decision maker.

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If you don't know how hospice works, then you are not the only one.

“There are many misconceptions about hospice care, and we often get questions about where, what, and how hospice services are provided,” says Amy Tucci, president of the American Hospice Foundation.

One of the most common questions her team gets asked is how to pay for hospice services.

Medicare and other hospice coverage

Although many types of Medicare coverage can be confusing, hospice Medicare coverage is very simple: it is covered. Completely, for the most part.

If you have Medicare Part A, there may be some costs:

• up to $5 copay for each outpatient prescription drug. However, Medicare Part D may cover these drugs;
• A fee of 5% of the Medicare-approved amount for respite inpatient care. This copay cannot exceed the annual inpatient deductible.

Medicare Advantage Plans cover hospice services and may even offer additional coverage beyond basic Medicare, such as a certain number of hours of assistance from a helper who is not in your hospice program.

Patients can choose from any Medicare-certified hospice provider in their area, ranging from one or two to 10 or even 50 in some states.

Most Medicaid programs in the state cover hospice services, and those that don't, Tucci says, usually have programs that cover hospice services. Veterans often receive hospice services through their VA insurance, which may contract with community hospices and also provide care through VA facilities, she said.

Many employer-sponsored and paid private health insurances cover hospice services, Tucci said, but it's a good idea to review your coverage.

Hospice Routine Care Coverage

You may be familiar with your local residential hospice, often known as a hospice, but this is not the norm for hospice services. In fact, to be certified by Medicare, a hospice program must have 80% of its patients in their own homes. Home is broadly defined as the place where the patient lives and can be a private home, nursing home, or other residential facility.

Hospice care at home is often misunderstood, says the president of the American Hospice Foundation.

“Hospice is a wonderful service designed to help family caregivers,” Tucci says. “But except in crisis situations, this care does not typically involve a registered nurse (RN) or certified nursing assistant (CNA) caring for the patient around the clock.”

According to Tucci, the average number of visits for a CNA is three times per week and for an RN at least once per week, but this can vary depending on the individual's care plan.

This is the first level of hospice care, called routine care.

“During the visit, a nurse or social worker will come to the home and assess what the patient needs,” Tucci explains. “They often order equipment such as a hospital bed and mattress, a bedside toilet and oxygen to be delivered to their home, along with any medications needed to treat symptoms. The nurse usually explains how to administer medications and perform daily nursing tasks. A plan of care will be developed by the hospice team and shared with the family. The plan of care will address the medical, social, physical and spiritual needs of the patient and caregivers.”

While family members are responsible for most care needs, the multidisciplinary hospice team will assist and advice is available through the 24/7 hospice hotline.

Additional care and services provided by the hospice

In addition to regular care, Medicare-certified hospices must provide three levels of hospice care.

Continuous home care: when a patient is in crisis and needs extra support, the hospice nurse can provide ongoing care services. This is usually only available during short periods of crisis if the patient needs help.

Interim inpatient care: if the caregiver needs rest, the patient may choose to be hospice in an approved residential facility for up to five days.

General inpatient treatment: if the pain or symptoms do not respond to other conditions, the patient may decide to be admitted to an inpatient hospice until the symptoms are resolved and the patient can return home later.

Respite care can also be provided in the home by trained hospice volunteers, if available. Under Medicare law, 5% of patient care hours must be provided by hospice volunteers, but this has been suspended during COVID-19. The Centers for Medicare and Medicaid Services (CMS) will restore this rule on January 1, 2024. Volunteers usually provide services such as communication, music therapy, aromatherapy, or household help.

Social workers and counseling psychologists are available both during the hospice stay and after the death of a loved one. Medicare-approved hospice providers are required to provide support to a loved one of the deceased for 13 months, Tucci said. This often comes in the form of support groups both in person and online.

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General Costs Not Covered by Medicare-Approved Hospice Providers

“Sometimes caregivers need or want to hire additional caregivers to manage the 24-hour care of their loved one,” Tucci says. “These costs are not typically covered, although, as mentioned, some Medicare Advantage plans may cover limited additional assistance.”

Other expenses that are not covered:

transport by ambulance if not arranged by the hospice. If you think your loved one needs emergency care (such as from the hospital to your home) for their comfort and well-being, check with your hospice provider to see if it is covered;

• room and board if the patient lives in a facility (such as a nursing home) and wants to receive hospice care there;
• conventional food and nutritional supplements;
• blood transfusion (this may be covered in your specific case - check with your hospice provider)
• emergency room visits or hospitalizations not authorized or arranged by the hospice;
• visits to specialized medical institutions for consultations related to terminal hospice diagnostics.

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