For qualified patients, original Medicare pays 100% of allowable charges from hospice agencies. This covers a wide range of home-based services such as nursing, equipment, medications, physical therapy, speech therapy, supplies, and more. Medicare pays all hospice charges regardless of copays or deductibles. This can be a major help for families that have often incurred considerable medical expenses up to the point of qualifying for hospice.
Hospice coverage may not be equal among all insurers. Medicaid tends to pay 100%. Private insurance may not. Medicare Advantage plans such as those through Humana or United may or may not pay 100% for all certified providers, and they may not cover the same services. Outside of original Medicare, each contract can differ.
Who Qualifies for Hospice?
For doctors and hospice agencies, this can be a complicated question. The umbrella answer is that people who have a life-expectancy of six months or less qualify for hospice. Life-expectancy or survival prognosis is an educated guess based on experience with the diagnosis. It does not mean anyone is giving up, but survival prognosis does help with the most appropriate medical and life planning. Additionally, Medicare does not pay for hospice while people are pursuing cures. Medicare reserves hospice for situations when medicine has no cures to offer that a patient finds worthwhile. Finally, hospice patients need to be under the care of a doctor who can certify the survival prognosis.
Hospice qualifications become complicated when doctors and hospice agencies dive into the question of when a specific person has six months. Every diagnosis has its own set of indicators for a six-month survival prognosis. The indicators tend to be technical. What’s more, the standards are not uniform across the country. With Medicare, prognostic guidelines are set by administrative contractors, not by Medicare itself. Medicare administrative contractors (MACs) work with healthcare providers to administrate Medicare benefits for specific regions. Because MACs each issue slightly different guidelines for Medicare benefits, the rules can differ by region.
What Does Hospice Cover?
The primary service in hospice is home nursing to help with rest, comfort, and symptom management. However, original Medicare covers a broad range of services, equipment, and medication under the one hospice benefit.
- Aide service for support with activities of daily living such as bathing, grooming, medication reminders, and light housekeeping.
- Volunteer coordination so volunteers can provide companionship and support with activities of daily living such as running errands or helping around the house. Many hospices also coordinate chaplain services. Hospice volunteerism can also include specific programs such as music therapy programs or comfort dogs.
- Therapies: This is primarily physical therapy, occupational therapy, and speech therapy for palliative care. However, should an agency choose to provide other similar services such as respiratory therapy or dietitian services, these would be included in the hospice benefit.
- Diagnosis-related medications. Hospice would not pay for all a patient’s medications, but it would pay for the medications related to the hospice diagnosis.
- Diagnosis-related supplies such as wound care supplies, catheters, etc.
- Diagnosis-related equipment such as hospital beds, bedside commodes, walkers, etc.
- Bereavement support: Care doesn’t end after a patient passes. Hospice stays in touch with spouses and close family members and provides bereavement support for up to six months.
In conclusion, hospice enables patients to receive the best possible palliative care in the comfort of home. The benefit under original Medicare is virtually all-encompassing. Medicare pays 100% of allowable charges without regard to co-pay or deductibles. To qualify, patients are not participating in curative treatments and have a survival prognosis of six months or less.