Medicare’s Hospice Benefit: Little Known, Little Used

Coping with a terminal illness can be a difficult enough experience without having to worry about pain management, medication costs, and assistance with caregiving. Surprisingly, many Medicare beneficiaries are unaware that Medicare’s all-inclusive Hospice Benefit is available to assist dying patients and their families with these issues at the end of life.

The hospice benefit is “grossly underutilized,” says Mary T. Berthelot, a staff attorney with the Center for Medicare Advocacy. In 2000, only 23 percent of Medicare beneficiaries who died were enrolled in a hospice program.

Hospice care offers a team-oriented approach to medical care, pain management, and emotional and spiritual support tailored to the dying patient’s needs and wishes. For patients who qualify, Medicare will pay for this kind of comprehensive end-of-life care delivered at home or in a hospice facility. The Medicare benefit includes many services not generally covered by Medicare and more than 90 percent of the more than 2,500 hospices in the United States are certified by Medicare.

What the Hospice Benefit Covers

Medicare will cover any care that is reasonable and necessary for easing the course of a terminal illness. Services are usually provided in the home. The Medicare Hospice Benefit provides for:

• Physician and nurse practitioner services
• Nursing care
• Medical appliances and supplies
• Drugs for symptom management and pain relief
• Short-term inpatient and respite care
• Homemaker and home health aide services
• Counseling
• Social work service
• Spiritual care
• Volunteer participation
• Bereavement services

Services are considered appropriate if they are aimed at improving the patient’s life and making her more comfortable. Physical, occupational and speech therapy, and even chemotherapy, may be covered if they are for comfort, not cure.

Medicare will also pay for a hospice physician to consult with terminally ill patients who are not yet in a hospice. The consult, which could occur in a hospital, nursing home, other facility, or at home, may include a pain assessment as well as counseling on care options and advance care planning.

One of the most important hospice benefits is its coverage of medication related to the terminal illness, which is covered at no more than a $5 copay. This alone can save a family a huge amount of money, since pain medication is extremely expensive.

Who Is Eligible?

To be eligible for Medicare’s hospice benefit, a beneficiary must be entitled to Medicare Part A and be certified by a physician to have a life expectancy of six months or less if the illness runs its expected course. But living longer than six months doesn’t mean the patient loses the benefit. After the initial certification period, each beneficiary receives an unlimited number of additional 60-day periods. People can live for years on the hospice benefit as long as their physician or hospital medical director still believes that they have a life expectancy of six months or less.

In addition, the patient must sign a statement electing the hospice benefit. By doing so, he is foregoing treatment to cure his illness and electing to receive only care to make his last days more comfortable, called “palliative” care. This is a big step for many patients and their families. The patient himself must make this election, provided he has capacity.

A patient is not locked into the benefit once he elects it, however. It’s possible to revoke the benefit and reelect it later, and to do this as often as needed. There also is no requirement that the hospice beneficiary be homebound. And, contrary to popular belief, Medicare does not require patients to have a “do not resuscitate” order or advance directive to be admitted to a hospice program.

Benefit recipients are allowed to keep their regular physician or nurse practitioner, and there may be a value in having an independent medical professional overseeing the care a patient receives from a hospice.

What if the hospice beneficiary is a nursing home resident? The Medicare hospice benefit does not cover room and board in a nursing home, but if Medicaid (or some other payer) foots this bill, Medicare will pay for care related to the terminal illness. However, there must be a contract between the nursing home and the hospice providing the care, and this is something to look into when selecting a nursing facility.

Many have the misconception that hospice care is reserved only for the last days of life. Sadly, the average length of stay in a hospice is a mere 25 days. But according to advocates, a frequent comment from patients and family members is “I wish I had it sooner.” Although the Medicare benefit cannot begin until six months prior to death, hospices in some states can begin delivering services much earlier.