What is Medicare?

Medicare is a federal health insurance program for senior citizens age 65 or older and certain younger individuals with qualifying disabilities.

Medicare coverage is divided into four parts:

• Medicare Part A covers hospital care, hospice care, nursing home care, skilled nursing facilities and home health services.

• Medicare Part B helps cover the costs of doctor’s visits, medical equipment, outpatient hospital care,and other services.

• Medicare Part C, often called a Medicare Advantage Plan, is offered by a private insurance company contracted with Medicare to facilitate Medicare Part A and Part B benefits. It may also include additional coverage including vision, dental, and hearing. Most Medicare Advantage Plans also offer prescription drug coverage.

• Medicare Part D is prescription drug coverage. Part D is a standalone program offered by private Medicare-approved plans. Many Part D offerings are bundled with Part A and Part B to form Medicare Advantage plans.

Does Medicare cover hospice?

The United States government established the Medicare hospice benefit program in 1983 to provide terminally ill patients with quality end-of-life care without a financial burden. In order to receive the Medicare benefit, an individual must meet the following Medicare hospice eligibility criteria:

• Medicare Part A coverage

• A diagnosis of six months or less to live

• A desire to pursue comfort care over curative treatment

• Once a patient meets these Medicare hospice guidelines and formally elects to receive hospice care, their hospice benefits are divided into benefit periods: the first 90-day benefit period, the second 90-day benefit period, and then an unlimited number of 60-day benefit periods. After each benefit period, the patient must be recertified to ensure they continue to meet the qualifications for hospice care.

What hospice services does Medicare cover?

Once an individual meets the Medicare hospice eligibility criteria, many of the costs of hospice care will be covered by Medicare. These include:

• Your hospice care team: Highly trained nurses, aides, social workers and chaplains provide care to meet the patient’s physical and emotional support needs. The team works alongside the patient’s family caregivers and/or long-term care facility staff to provide care and education.

• Medical equipment: The Medicare hospice benefit covers the cost and delivery of necessary equipment like a cane, walker, wheelchair or hospital bed.

• Medical supplies: The Medicare hospice benefit fully covers necessary medical supplies including incontinence supplies, catheters and bandages.

• Prescriptions: Non-curative prescriptions prescribed by the patient’s physician to manage the pain and symptoms associated with their terminal illness.

• Bereavement counseling: Bereavement coordinators offer comfort, support and guidance to the patient and to their family after the patient has passed away.

• Short-term inpatient care: If the patient’s symptoms temporarily require the resources of an inpatient facility, the Medicare hospice benefit will cover this until the symptoms are controlled and the patient returns to their primary residence.

• Short-term respite care: The Medicare hospice benefit covers up to 5 days at an inpatient care facility for the patient to allow the family caregiver time to rest.

• Speech, physical, nutritional and occupational therapies: The patient’s hospice care team can provide additional supportive care to improve quality of life and manage symptoms related to the patient’s terminal illness.

The individual’s original Medicare coverage will continue to cover the non-curative healthcare costs that are not directly associated with their terminal illness.

Hospice and Medicare restrictions.

The Medicare hospice benefit covers most costs related to a patient’s terminal diagnosis, but there are some treatments and costs not covered by this benefit program. These include:

• Curative treatment: The Medicare hospice benefit does not cover any costs associated with treatment or medication designed to cure a terminal illness.

• Care not provided or arranged by the selected hospice organization: All care the patient receives for the terminal illness must be provided or arranged by the patient's chosen hospice organization. The primary care physician can continue to collaborate with the hospice care team.

• Room and board: If the patient resides in a nursing home or other long-term-care facility, the room and board charges will not be covered by the Medicare hospice benefit.

• Skilled nursing care: The Medicare hospice benefit will not cover any day when a patient receives skilled nursing care, including wound care, physical therapy and occupational therapy.

Inpatient respite care: Medicare does cover the majority of the cost of inpatient respite care, but patients may be responsible to pay 5% of the Medicare-approved amount.

Applying for hospice services.

In order to apply for hospice services, the patient must meet certain medical eligibility requirements and have a referral from a physician. Hospice services are available to patients who have been determined to have less than six months to live, should their disease run its typical course.

Medicare and hospice guidelines FAQ.

Does Medicare cover hospice in a nursing home or other long-term care facility? • Yes, hospice services can be provided to eligible patients in their nursing homes or long-term care facility, as well as their personal home or a hospital.

Can a patient receive skilled nursing care and hospice care at the same time? • Medicare regulations prohibit patients from receiving concurrent enrollment in hospice and skilled nursing care for the same diagnosis. In rare cases, a patient may receive skilled nursing care for a diagnosis unrelated to their terminal illness while receiving hospice services.

Learn more about Medicare hospice eligibility criteria.

If you know an individual who may be eligible, or soon eligible, for hospice care, please contact us through the contact form. Pathway Hospice staff are available to answer questions 24 hours a day, 7 days week, 365 days a year.

Medicaid is a jointly funded, federal and state program that provides free or low-lost health insurance coverage to low- income families, pregnant women, the disabled and the elderly. In most states, Medicaid participants are eligible to receive hospice care when they have been diagnosed with a terminal illness with a medical prognosis of less than six months to live if the illness runs its normal course.

Medicaid coverage can be used alongside the patient’s existing Medicare coverage. If the patient elects to use the Medicaid hospice benefit, this does not eliminate Medicaid coverage for other symptoms or conditions not associated with their terminal diagnosis.

While each state’s Medicaid program may have slight differences in hospice eligibility requirements, most states require the following:

• Certification of terminal illness by the patient’s physician

• Patient must agree they are accepting hospice care by completing an election form

• Patient must agree to discontinue curative treatment, unless they are under 21 years old

• The patient’s physician must state that they have a reduced life expectancy as defined by their state each time they certify eligibility

What hospice services does Medicaid cover?

States are required to offer hospice benefits divided up into set review periods. At the end of each time period, hospice care eligibility must be recertified by a physician.

The Medicaid hospice benefit covers services provided by a skilled hospice team to meet your physical, psychosocial, emotional, and spiritual needs. These include:

• Hospice physician services

• Hospice nursing care

• Hospice aide services

• Medication for symptom control and pain relief

• Medical equipment and supplies

• Short-term inpatient care for pain control and symptom management

• Social worker services

• Chaplain support

• Respite care

• Bereavement counseling

• Physical, speech, occupational, dietary and other therapies

The patient’s hospice team works alongside their family and physicians to provide the care and comfort they need for the highest possible quality of life.

Hospice and Medicaid restrictions

The Medicaid hospice benefit is a provision of the state, and each state may cover different end-of-life care services. Most states model their coverage on the federal Medicare model, which restricts certain treatments and services including:

• Curative treatment: The Medicaid hospice benefit requires patients discontinue curative treatment to begin hospice care. The one exception to this is for patients under the age of 21 who may be able to continue curative treatment while receiving comfort care.

• Care not provided or arranged by the selected hospice organization: Once a patient begins receiving hospice services, all care for their terminal illness will be coordinated by the hospice organization.

• Room and board: The Medicaid hospice benefit does not cover room and board fees if the patient resides at a nursing home or other facility.

• Skilled nursing care: If a patient has received skilled nursing care for their terminal illness, the • Medicaid hospice benefit will not cover hospice services until the following day.

• Inpatient respite care: Patients may be responsible for paying 5% of the Medicaid-approved amount for short-term in-patient respite care.

Applying for hospice services.

Once a patient meets the criteria listed above, they are eligible to begin hospice service. Pathway Hospice will meet with patients and their families to admit the patient and begin care.

The Pathway Hospice nurse will be happy to answer any questions the family has about hospice services and the admissions paperwork. We are able to begin delivering hospice services, equipment, and supplies as soon as the patient is admitted, ensuring a smooth transition into hospice care for the patient and their family.

Medicaid & hospice frequently asked questions.

What is the cost of hospice care for patients using Medicaid? • Hospice services are typically 100% covered with no out-of-pocket costs for patients and their families. They typically see no bills for hospice services as the hospice care reimbursement is handled between the hospice care organization and Medicaid.

Where are hospice services provided? • Hospice services can be provided wherever the patient currently resides including their home, a hospital, a nursing home or assisted living facilities. Pathway Hospice will provide hospice services wherever the patient calls home.

What if I want to discontinue hospice services? • If a patient wishes to discontinue hospice services, they may sign out any time. If the patient begins to improve under hospice care and no longer meets the hospice eligibility criteria, they may be discharged from hospice care. The patient may return to hospice care if their illness progresses and they are once again certified with a terminal illness with a prognosis of six month of less to live if the disease follows its typical course.

When should a patient begin hospice care? • The one thing we hear most from patients and families is that they wish they had known they could start hospice services earlier in their terminal diagnosis and taken advantage of the added support available to them. Experts agree that hospice patients receive the greatest benefit when they utilized hospice services for at least two to three months. In fact, studies show that patients receiving the support of hospice care live an average of 29 days longer than those who do not elect to use their hospice benefit.

Learn more about Medicaid hospice benefits.

The Medicaid hospice benefit allows low-income individuals, individuals with a disability and the elderly to receive quality end-of-life care from a team of skilled hospice professionals.

Pathway Hospice is available 24 hours a day, 7 days a week, 365 days a year to admit patients and provide care. Our admissions team can meet patients and their families in the location that works best for them including their home, the nursing home, a hospital, a workplace or a nearby library, coffee shop or café.

While most patients use Medicare or Medicaid for hospice services, some patients use private health insurance plans to cover hospice care.

Private health insurance plans protect patients and their families from paying the full cost of medical expenses for illnesses, injuries and medical conditions. This is most often provided by an employer or retirement program, but it may also be purchased privately from a health insurance provider or through the Affordable Care Act Marketplace.

Most private insurance plans cover hospice care and other end-of-life care services. These insurance plans typically cover the full cost of hospice services. However, each health insurance company may have its own unique requirements a patient must meet before they can begin hospice care.

At a minimum, most private insurance plans require that the patient be diagnosed with a terminal illness with a reduced life expectancy of six months or less. They also require that a patient discontinue curative measures before beginning hospice care.

What hospice services does private insurance cover?

The majority of private insurance plans model their hospice insurance coverage on the federal Medicare hospice benefit program and cover 100% of hospice costs. It is important to contact the insurance provider for specific details on what the patient’s plan will cover and what costs the patient may be responsible for.

Hospice services include:

• A highly skilled team of physicians, nurses, hospice aides, social workers, chaplains, bereavement coordinators and volunteers.

• Medical equipment related to the patient’s terminal diagnosis including wheelchairs, hospital beds, and walkers.

• Necessary medical supplies including bandages and other wound care supplies, incontinence supplies, and catheters.

• Medications prescribed by the patient’s physician to manage pain and control symptoms related to their terminal diagnosis.

• Short-term in-patient care if needed to manage symptoms related to the patient’s terminal diagnosis.

• Short-term respite care for up to 5 days for the patient at an inpatient care facility to give family caregivers the chance to take a break.

Patients should always speak with their health insurance provider about these services, so they have the peace of mind of knowing what services are and are not covered.

Private insurance hospice coverage FAQ.

What services are covered by the insurance policy’s hospice plan? • The insurance provider will confirm what services are covered by the patient’s existing plan.

Are there any out-of-pocket expenses? • It is important to understand what copayments and deductibles the patient and their family may be responsible for, so they can plan for these expenses.

How does Pathway Hospice bill private insurance for hospice care? • Pathway Hospice bills private insurance providers directly for patients with private insurance coverage or other third-party payers. Patients are responsible for charges not paid by their insurance provider.

What if a patient is under-insured or uninsured? • Pathway Hospice works with patients and families who meet hospice care eligibility to ensure they have the support they need regardless of their ability to pay for services.

When is the patient eligible for hospice care? • Most patients are eligible for private insurance hospice coverage when they have been diagnosed with a terminal illness with six months or less to live if the disease follows a typical progression.

Get the care you need now.

Pathway Hospice provides patients and their families with a team of hospice care professionals who will address the patient’s physical, psychosocial, emotional and spiritual needs at end of life.

If you know someone who may be eligible for hospice services, please contact us by giving us a call or filling out our contact form. Our team is available 24 hours a day, 7 days a week, 365 days a year to answer questions, admit patients and provide care.