Transcript Medicare Hospice Benefit

Adapted from CMS guidelines Aug
2013 for Ambercare Corporation
Education Department 2014
What is Hospice?
• Hospice helps people who are terminally ill live comfortably
• Hospice isn’t only for people with cancer
• The focus is on COMFORT MEASURE CARE, NOT curing illness
• A specially trained team of professionals and caregivers provide care
for the “whole person”, including his or her physical, emotional,
social, and spiritual needs
• Services may include: physical care, counseling, medications,
equipment and supplies for the terminal illness and related
condition(s)
• Care is generally provided in the home (can be an Assisted Living,
Nursing home facility or a Residential care facility)
• Family caregivers can also receive support
The Medicare Hospice Benefit – who
qualifies?
• If you are eligible for Medicare Part A (Hospital Insurance)
• Your doctor and the hospice medical director certify that you are
terminally ill and have 6 months or less to live if your illness runs its
normal course
• You sign a statement choosing hospice care instead of other Medicarecovered benefits to treat your terminal illness (Medicare will still pay
for covered benefits for any health problems that aren’t related to
your terminal illness)
• You get care from a Medicare-approved hospice program
How does hospice work?
• Each patient is assigned a specially trained team and support staff
available to help patient and family cope with the illness
• Team members may include:
• Doctors
• Nurses or nurse practitioners
• Counselors (chaplain)
• Social workers
• Physical and occupational therapists
• Speech-language pathologist
• Hospice aide
• Volunteers
How hospice works…continued
• Hospice nurse and doctor are on-call 24
hours a day/7 days a week
• The hospice benefit allows you and your
family to stay together in the comfort of
your home unless you need care in an
inpatient facility (such as uncontrolled
pain, nausea, bleeding, etc.)
What Medicare covers:
• Important to note: Medicare covers benefits for any health problems
that AREN’T RELATED to the terminal illness (like care from an injury –
fall as an example)
• What is covered under the hospice benefit?
•
Doctor services (visits for example)
•
Nursing care (generally two x week or more if warranted)
•
Medical equipment (wheelchairs, walkers, recliners, etc.)
•
Medical supplies (wound care supplies, etc.)
•
Medications (for symptom relief, pain control)
•
Hospice aid services
•
PT, OT, ST
•
Social work services / dietary counseling
•
Grief, loss, spiritual and bereavement counseling
•
Short term respite care
What Medicare won’t cover:
• Treatment intended to cure your terminal illness (as a hospice patient,
you always have the right to stop hospice care at any time)
• Prescription drugs to cure your illness (rather than for symptom control
or pain management)
• Care from any hospice provider that wasn’t set up by the hospice
medical team
• Room and Board (Medicare does not cover room and board if you get
hospice care in your home or live in a nursing home or a hospice inpatient
facility; however, Medicare will cover room and board if the hospice team
deems that short-term inpatient or respite services are needed
• Care in an emergency room, inpatient facility care, or ambulance
transportation (unless it’s either arranged by your hospice team or is
UNRELATED to terminal illness)
Medicare pays the hospice provider
• What does the patient pay?
• Generally $5 co pay for each prescription drug and other
similar products for pain relief and symptom control
• 5% of the Medicare-approved amount for inpatient
respite
• For example: if Medicare pays $100 / day for inpatient
respite care, the patient would be responsible for $5 /
day (can change annually)
HMO / PPO or other Medicare health
plan?
• All Medicare-covered services provided while receiving hospice care are
covered under Original Medicare, even if the patient has a Medicare
Advantage Plan (like an HMO or PPO) or other Medicare health plan
• Includes any Medicare-covered services for conditions UNRELATED to
terminal illness provided by attending doctor.
• A Medicare Advantage Plan is a type of Medicare health plan offered by a
private company that contracts with Medicare to provide Medicare Part A
and Medicare Part B benefits; however if the plan covers extra services
not covered by Original Medicare (like dental and vision benefits), the
plan will continue to cover those extra services
Receiving care for a condition OTHER
than Terminal Illness
• Continue to use Original Medicare to receive care for any health care
needs that AREN’T related to your terminal illness
• Can receive care from the hospice team doctor or own doctor
• The hospice team determines whether any other medical care needed is
or isn’t related to terminal illness so as not interfere with hospice benefit
• Medicare Supplemental Insurance (MEDIGAP) policies
•
If patient has Original Medicare, Medigap covers hospice costs for medications and
respite care along with covering any other health care costs for problems NOT
related to terminal illness
Receiving hospice services – how long?
• Intended for patients with 6 months or less to live if the disease process
runs its normal course
• If patient lives greater than 6 months, patient can be recertified by
hospice physician if deemed hospice appropriate (meets criteria as noted
previously)
• Benefit periods:
•
2 – 90 day periods
•
Followed by unlimited number of 60-day periods
•
At the start of each period, the hospice physician must recertify that patient is
terminally ill;
•
A benefit period starts the day patient receives hospice care and ends when the 90day or 60 day period ends
•
Patient has the right to change hospice providers only ONCE during each benefit
period