Does Medicare Cover Hospice?

Many people are still not very familiar with Medicare and hospice.  It is actually a fairly new idea.  The “end of life movement” began in the ’70s.  (The “end of life movement” is separate and distinct from the Euthanasia movement and organizations, like the Hemlock Society.)  Medicare did not cover Hospice when Medicare started in 1965.  Medicare and hospice were only put together in 1982 as part of the Tax, Equity, and Fiscal Responsibility Act under President Reagan in response to a growing awareness of end of life concerns.  The legislation was an attempt to fill the gap in care.  Awareness was growing in the country of the importance of what transpired at the end of life.

A Happy Death Is Not A New Idea

I remember when I was a teenager.  My father was up before me in the mornings.  He would take me to school on his way to work.  I would see him praying when I came into the kitchen in the morning.  One time I asked him what he was reading.  It was a small devotional booklet.  He was praying the novena to St. Joseph for a “Happy Death.”  I was startled by the subject matter.

Teenagers don’t think much about death unless forced.  I had a buddy, Herbert Woltz, killed in a motorcycle accident my senior year in high school.  That was my abrupt intro to death.

I asked my father why pray for such a crazy thing as a “happy death”?  The two subjects were oxymoronic to me.  What’s happy about death?  He reminded me that is how the Hail Mary ends.  “Pray for us . . . now and at the hour of our death.  Amen.”

After birth, he said, death is the most important event in your life.  The difference, however, is you’re aware of what’s going on in the end, and you make the most important decisions of your life at “the hour of your death.”  Praying for a “Happy Death” is about minimizing the pain and maximizing your moment of entrance into eternity.  You’re asking for God and all the heavenly hosts to be at your side to handle the fear, pain, discouragement, and loneliness a person faces when approaching death and the moment of death.

I didn’t think much about what my father shared until many years had gone by and many friends and family members had passed away, including my dad.  Medicare and hospice are something with which I have had extensive experience.  Now I know why you would want to pay for a “happy death.”

End of Life Care Is Different

As a seminary student in St. Paul, Minnesota in the early 80’s, I was looking for a part-time ministry when I wasn’t at school studying.  I found the Hawthorne Dominicans.  The Hawthorne Dominicans is a Catholic women’s religious order devoted to the terminally ill.  They had a hospice facility near my college, so I would walk down to it and help out on weekends.  Most of the patients were cancer patients.  My work was minor cleaning, but mainly it was visiting with the patients.  Keeping up their spirits.  Show them someone cared as they were coming to the end of their lives, and I would join the sisters in prayer and mass for the residents.

While I was there, I got to know the sisters.  They were remarkable young ladies.  The convent was inside the hospice facility.  The nuns lived, prayed, and worked with their dying residents around them twenty-four hours a day.  The Hawthorne Dominicans were some of the happiest people I ever met.

Their foundress, Rose Lanthrop-Hawthorne, was the youngest daughter of the famous author, Nathanial Hawthorne, and a convert to Catholicism.  In her day, cancer patients were put on an island in New York harbor–Blackwell Island–because it was believed that cancer was contagious.  Many people, especially the poor, died in incredible misery, isolation, and squalor.

Medicare and hospice were a century away.  Rose, like Mother Teresa of our time, saw the face of Jesus in the poor, and she started a ministry to the dying among the poor immigrants of the New York slums.  The Hawthorne Dominicans is a purely American woman’s religious order.  Most woman’s religious orders in our country came from Europe originally.

End of Life Care Rediscovered With Hospice & Medicare

The end of life movement in our time found its origin during a 1967 lecture at Yale University by Cicely Saunders.  She introduced the idea that the dying needed specialized care that served their unique situation.  She later founded St. Christopher’s Hospice in London.

Dr. Elisabeth Kubler-Ross, MD research into death and dying identified five stages terminally ill patients go through.  Her popular and groundbreaking book, On Death & Dying, fueled a movement to deal with issues of death and dying.

In 1972 she testified at the first national hearings on death with dignity conducted by the U.S. Senator Special Committee on Aging.  Organizations, like The National Hospice and Palliative Care Organization (NHPCO), sprang up to study and promote awareness around the end of life issues.   Finally, because of raised public interest and concerns, Medicare added hospice care to the list of services provides in 1982.

Medicare And Hospice Are Huge

In 2014 approximately 2.6 million people died in the US.  Of those deaths, 80% were on Medicare.  Medicare is the largest insurer for persons during the last year of life.  A quarter of the Medicare budget is just for those who are in the last year of life.  That number has been consistent for decades.  The high cost of health care at the end of life is not surprising considering the number and complexity of health issues, so CMS (Center for Medicare & Medicaid Services) is acutely aware of end of life issues.

Today, hospice is an important benefit for terminally ill Medicare beneficiaries.  Currently, nearly half of Medicare beneficiaries receive hospice benefits before their deaths.  Medicare is the primary source of payment for hospice care in this country.  Yet, hospice still remains somewhat of a mystery, and Medicare beneficiaries know very little about what Medicare does with hospice until they are forced into the situation.

How Does Medicare Cover Hospice?

Hospice is defined as a program of care and support for people who are terminally ill.  Terminally ill means a life expectancy of six months or less.  The primary goal of hospice in Medicare is to help terminally ill people live a comfortable life and manage their pain and discomfort.  Hospice care is palliative care versus skilled nursing and home health care.  That is, it is not designed to cure the patient, but rather to aid the person in the dying process.  Because hospice care is so intimately involved and in such a big way with Medicare beneficiaries, understanding Medicare and hospice is essential.

Prayer to St. Joseph 

O St. Joseph whose protection is so great, so strong, so prompt before the throne of God, I place in you all my interests and desires. O St. Joseph do assist me by your powerful intercession and obtain for me from your Divine Son all spiritual blessings through Jesus Christ, Our Lord; so that having engaged here below your heavenly power I may offer my thanksgiving and homage to the most loving of fathers. O St. Joseph, I never weary contemplating you and Jesus asleep in your arms. I dare not approach while He reposes near your heart. Press Him in my name and kiss His fine head for me, and ask Him to return the kiss when I draw my dying breath. St. Joseph, patron of departing souls, pray for us. Amen.

John Joseph Grimmond 1934-2013  R.I.P.

What Is Medicare Hospice?

Death & dying is an area most people do not wish to ponder, so there are many misconceptions about Medicare-covered hospice care.

What Medicare Hospice Is Not?

Hospice is not a place.  When my mother was terminally ill with ovarian cancer, I was thinking of taking her to a place.

When I was in college in the 80s, I had volunteered in a hospice facility run by the Hawthorne Dominican sisters.  The hospice facility was an actual place people went to die.  The nuns took care of everything: medical, personal care, food & lodging; and patients stayed there until the end.

That is what I had in mind when the doctors spoke to my family about hospice for our mother.  That is not, however, how Medicare thinks of hospice. 

Medicare does not pay for a hospice facility that provides room & board unless the care is tied to something like a skilled nursing facility.  Medicare does, however, pay for hospice personnel and the medications they administer during hospice.

Where Do You Go For Hospice?

Hospice can be given virtually anywhere.  A Medicare beneficiary can receive hospice at a hospital, hospice in a skilled nursing facility, hospice in an assisted living residence, and hospice at home.  Medicare will pay for hospice care in assisted living, nursing homes, and other facilities if it is a Medicare-approved facility.

The end of life movement that started in the ’70s sees passing at home as the ideal.  Most Medicare patients, when surveyed, prefer hospice in the home.  That is where people feel most comfortable, but because of the level of care required, hospice care may have to move to a hospital in the last few days or another location.

Hospice can be given virtually anywhere. 

Medicare.gov

What Kind of Illness Makes You Hospice Eligible?

When we think of hospice, we usually think of cancer, but there are other illnesses that result in hospice.

Grandpa Joe was 98.  Grandpa had beaten cancer 4 times, lockjaw, and the Second World War.  Dying didn’t seem possible. He had always been there, and we grandkids assumed he would always be there. Terminal illness and Grandpa Joe didn’t fit. 

When Grandma Hilda announced to the family, Grandpa had congestive heart failure and was going into hospice, it didn’t quite register with us grandkids. 

Grandpa Joe seemed the same old Grandpa Joe. When I was home from college, we chatted about the Cornhuskers, baseball, and politics.  Nothing seemed to have changed, but there was a procession of nurses and therapists who came in and out of their home.

When Grandma Hilda finally called to tell us Grandpa had passed in his sleep, his death hit me like a sledgehammer.

Grandpa’s passing was hard on everyone, but Medicare providing and paying for hospice lightened the burden, especially for my parents and grandparents.

Who Can Go Into Hospice?

Hospice is also not exclusively for the old.  I have a number of clients who are in their twenties and thirties.  Not everyone on Medicare is sixty-five and older, though the majority are. 

Accidents or illnesses permanently disabled some, and some are terminal.  Hospice is for them too.

How Much Is Hospice?

Hospice care is not expensive for those on Medicare.  Medicare pays for the vast majority of the hospice costs under Medicare Part A with very little out-of-pocket costs.  Medications, some equipment, and nurses are covered. 

Like I said earlier, hospice does not usually include custodial care or housekeeping.  That can be very costly if the family cannot provide that type of care themselves.

How Do You Get Medicare To Pay For Hospice?

A Medicare beneficiary is eligible for Medicare’s hospice care benefit if she is entitled to Medicare Part A and meets the following conditions.

1. The hospice doctor and the person’s regular physician certify that the person is terminally ill with a life expectancy of six months or less if the illness runs its expected course.
2. The person accepts palliative care for comfort instead of care to cure her illness.
3. The person must sign a statement choosing hospice care instead of other Medicare-covered treatments for her terminal illness and related conditions.
4. The care is provided by a Medicare-certified hospice agency.

When these 4 critical are met, Medicare pays for hospice. At any time, a person may choose to exit hospice.

Is Hospice Euthanasia?

Hospice does not accelerate the dying process. 

I have had people describe hospice to me as akin to euthanasia where someone actively terminates a life.  Hospice is not euthanasia or assisted suicide.  You do not intentionally cut short a person’s life.  Hospice is about allowing the dying process to take its natural and inevitable course without assistance.  Hospice care is about alleviating the suffering and providing comfort while the person dies.

An uncle of mine was a retired Omaha police captain. Uncle Bill had a severe stroke with many complications.  He was put on a ventilator. 

Uncle Bill was a strong and courageous individual.  A vegetative existence was not for him not to mention impoverishing his wife with medical bills.  He ordered the ventilator turned off.

Without the ventilator, he would quickly stop breathing.  He knew it.  The doctors made him as comfortable as possible with heavy sedation.  His body fought hard against the loss of breath.

We gathered around his hospital bed.  Over the course of a day, he passed peacefully from this life to next surrounded by his loving wife and children.

Hospice Is Up To You

I’ve known many individuals over the years who have gone on hospice for a time.  Instead of dying, their health improved, or they resumed a normal life and quit hospice because the decline stopped.  You are free to remove yourself from hospice at any time.

Hospice Is Also For The Living

Hospice is the option when all other alternatives have been exhausted.  It is the option to bring the highest possible quality of life to a person’s remaining time.  The hope is family members will look back on their time and know that everything was done to preserve, prolong, and then peacefully say goodbye.

While you may struggle with the challenge of terminal illness, the end of your life and hospice is as much about your loved ones as it is about you.  Watching you suffer and your family’s grief afterward will be their burden.  Dying is equally about them.  Understanding that there is something for them as well as you in a scary time can give you all hope that the last great challenge in life will be a little less daunting.

While hospice ends with a patient’s death, family grief counseling can continue for up to a year.  Medicare pays for that hospice care too.

One’s mortality is difficult to face, but the chance you will go on Medicare hospice at the end of your life is more than 50%.  That is an extraordinary number, so having confidence Medicare will pay for hospice is critical.

Medicare Advantage and Home Health Care

All Medicare Advantage (MA) plans must provide at least the same level of coverage for home health care as does Original Medicare, so Medicare Advantage pays for home health care.  However, an MA plan may have different rules, costs, and restrictions on services.  For example, depending on a person’s MA plan, it may require him to:

• Obtain care from a home health agency that has contracted with the plan.
• Receive prior authorization or a referral before receiving home health care.
• Pay a copayment for home health care.

Coverage of Non-Skilled Care and Other In-Home Support Services

Center for Medicare & Medicaid Services (CMS) recently announced that Medicare Advantage plan will be able to cover certain types of home health care related services that were not previously able to be offered, beginning in 2019.  This will be possible because CMS has expanded the definitional scope of “supplemental benefits” that Medicare Advantage plans can offer.  Starting in 2019, insurers can offer additional services to help improve enrollees’ health and quality of life.

Medicare Advantage Can Pay for Home Health Care Supplemental Benefits

Medicare Advantage plans may offer additions benefits not offered by Original Medicare.  Previously, CMS did not allow any item or service to qualify as a supplemental benefit.  Supplemental benefits were items of “daily maintenance.”  In other words, MA plans could not offer items and services that were not directly for medical treatments.  The agency has now reinterpreted the requirement for supplemental benefits to include a “primarily health-related” definition as follows:

an item or service that is used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization

Some Medicare Advantage Supplemental Benefits

Accordingly, this reinterpretation of supplemental benefits will allow Medicare health plans to offer coverage or benefits for the following:

• Adult daycare services  are services provided outside the home, such as assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs)
• In-home support services are services a personal care attendant provides.  She assists disabled or medically needy individuals with activities of daily living, such as eating, bathing, and transferring, and instrumental activities of daily living.  These activities may include managing money, preparing meals, and cleaning a house.  Services must be performed by individuals licensed to provide personal care services, or in a manner that is otherwise consistent with state requirements.
• Home-based palliative care services Medicare does not cover if life expectancy is more than six months.  Palliative care (“comfort care”) is to diminish symptoms of a terminally ill patient.
• Transportation for nonemergency medical services is transportation to obtain Part A, Part B, Part D, and supplemental benefit items and services.  The transportation must be used to accommodate the enrollee’s health care needs: it cannot be used for nonmedical services, such as groceries or errands.
• Home safety devices and modifications are safety devices to prevent injuries in the home and/or bathroom.  The modifications must be non-structural and non-Medicare covered.  This benefit can include home and/or bathroom safety inspection to identify any need for safety devices or modifications.

A physician or licensed medical professional must recommend these home care services.

Medicare’s expansion of MA plan benefits, like adult days care, helps patients remain in their homes as they age rather than being institutionalized, which could also result in lower costs for Medicare and Medicaid.

The Advantage of Medicare Advantage for Home Health Care

Medicare Advantage plans may impose different rules, limitations, and costs than Original Medicare, but they must provide at least the same level of home health care benefits.

Starting in 2019, Medicare Advantage plans may offer supplemental benefits that help enrollees with daily maintenance, including transportation for medicare services, in-home support services, and home-based palliative care.  Consult the individual MA plan for the details of coverage.

In the Omaha metro area, the MA plans offer some of these benefits.  Currently, the plans that do offer a lot of these benefits are the “Dual” or “Special Needs” plans.  Those plans are for a person on full Medicaid as well as Medicare or have some special needs because of chronic illness, such as COPD, Diabetes, etc.

In other areas with high population densities, many of the MA plans are much richer with benefits.  As it stands in eastern Nebraska and western Iowa, principally Omaha, Lincoln, Bellevue, and Council Bluffs, the supplemental benefits seem to be growing in number and scope each year.  A couple of insurance companies recently added transportation to their health plans.  More insurance companies are developing Medicare Advantage plans and including this type of home health services.

Know What Medicare A Covers

I have known veterans who only took Medicare A because it was free, and they opted out of  Medicare Part B for doctor and outpatient services because it cost something.  They thought Medicare A was enough because they could rely on the VA hospital.  The VA, however, changes what it will cover or reimburse, depending upon Congress’s budget and who is in the White House.  I had another gentleman in my office recently who thought Part B was unnecessary waste of money because he had been healthy all of his life.  While Medicare A is good insurance and covers some things, it is very limited if you understand how Part A works.  You should never guess about health insurance.  You need to know what Medicare A covers and doesn’t cover.

Medicare A was the first Medicare plan in 1965.  It covers hospital services.  Hospital stays are the most devastating and costly part of health care.  Medicare A covers five areas: inpatient hospital stays, blood, skilled nursing facilities, home healthcare, and hospice.  It does not cover these services completely.  There are deductibles, copayments, coinsurance, and limitations on days of service.

Medicare A Covers 60 Days In the Hospital

The deductible for Medicare A is currently $1,484 for 2021.  It has increased with a definite consistency over the years.  After the deductible is met, the patient is covered 100% for the next 60 days.   After a continuous 60 days as an inpatient in the hospital, the copay is $371 per day for Medicare A coverage.  The copay runs from days 61-90.  (This cost is assuming you have no other coverage, like a Medicare supplement.)

Lifetime Reserve Days for Medicare

Each Medicare beneficiary has 60 lifetime reserve days for Medicare A coverage.  This means the patient may dip into this limited number of days when they go past the 90-day mark.  If they use up those 60 days, they are not replaceable.  “Lifetime” means lifetime.  Even then, the 60 lifetime reserve days for Medicare have a copay of $742 for each day.  After the 150 consecutive days, the patient assumes ALL costs.  Of course, this is a rare event.

Hospital Stay Coverage Depends on the Day

Staying as an inpatient in a hospital for 60, 90, or 150 days is a very rare event.  The more likely occurrence is being admitted to the hospital, discharged, then readmitted for the same thing.  That is a number game in itself.  Once you are discharged, you need to be out of the hospital for 60 consecutive days.  If you are, then the clock starts over again when you are admitted, even if it is for the same reason.

The count starts back up where you left off if you return to the hospital within those initial 60 days.  If you left day 15 and are readmitted 30 days later, your second period in the hospital starts with day 16.  This is assuming the readmittance is for essentially the same reason. Hospital stay coverage depends on where you fall in the sequence of days.

Does Medicare Cover Blood Transfusions?

Medicare A covers blood and Medicare B covers blood, but in two different circumstances. Medicare does not cover the first three pints of blood. They wait until the fourth pint before they kick in. 

If the hospital gets the blood for the transfusion from a blood bank then you may not pay, other than donating blood afterward. Someone else may also donate blood in your name. If the hospital purchases blood, you will either pay or give you the option to donate.

Medicare A Covers Hospice Care

Hospice is for the terminally ill. Terminally ill means the medical prognosis is an expectation of six months or less of life, assuming the illness runs its usual course. Only a Medicare-certified hospice program may take a patient, and the program director, together with the attending physician, determines admittance to the hospice program. Medicare A covers the care totally except for some minor copays for medications.

What hospice provides is PAIN RELIEF. Everything—drugs, medical equipment, nursing, homemaker services—are all designed to reduce pain and maintain some reasonable level of comfort for the dying person. Hospice is generally administered at home.

Some people believe hospice will cover room and board and other housekeeping items in a hospice or nursing home facility. The individual and/or family will bear those costs, not Medicare.

Does Medicare Cover Skilled Nursing Facilities?

Skilled nursing is not nursing home insurance. I get this question almost every week. ‘What happens to me if I have to go to a nursing home?’ If it is not tied to a medically necessary reason for full-time rehabilitation, the nursing home will be on your dime unless you have long-term care insurance.

Skilled nursing care is not custodial care, which means bathing, transporting, feeding, etc. That is what most people imagine when they think of a nursing home. Skilled nursing is something else.

There are five criteria a person must meet to be admitted to the skilled nursing facility that Medicare A covers. The first criteria is a minimum 3-day inpatient hospital stay for a related illness. Then the doctor discharges you to a facility because you cannot continue your treatment on your own. For example, if you need injections or physical therapy. 

Second, you must enter the facility within 30 days of dismissal. Third, you can only receive the medically necessary treatment in a skilled nursing facility. You cannot receive the same or similar treatment through home health care or office visits. 

Fourth, the skilled nursing facility must be a Medicare-approved facility. Finally, the reason for the stay must be the same reason the patient was in the hospital.

Medicare A covers skilled nursing at zero cost for the first twenty days. However, on days 21-100, the patient pays $185.50 per day unless they have a Medicare supplement or other insurance. Like the hospital stay, there is a formula for starting and stopping the days and how they are counted.

Medicare A Covers Home Health Care

Medicare A covers home health care in much the same way as it covers skilled nursing facilities. There is a list of criteria the patient must meet. 

Home health care is like skilled nursing in that it provides skilled care–not custodial. The patient must be certified to receive it. They must be homebound. In other words, they cannot easily go to an office to receive treatment. Medicare will cover home health care completely under Part A for as long as medically necessary and can be verified as necessary. It will be at no cost to the beneficiary.

What Does Medicare Part A Not Cover?

Medicare A does not include Medicare B. Part B is doctor and outpatient procedures, which is the bulk of what most people need. Those are also doctor visits in the hospital.

Medicare Part B does cost something. The Part B premium is currently $148.50 per month per person unless your income is in the top 6%.

Some people who do not take Part B. Maybe they have VA benefits or some other coverage. That can be a mistake. 

Medicare A does not cover prescription drugs. Part D covers medications. Part A does not cover dental, vision, hearing, transportation. Those are all medically important services covered in other places and ways.

Medicare Part A Doesn’t Cover All Medical Costs 

You paid for Medicare A coverage during your working years. Your payroll taxes included a 1.45% tax for Medicare Part A. It was and is strong protection for seniors against the devastating cost of hospital stays. 

Skilled nursing is an important service, and Medicare A comes in to cover it. Home health care is vital for a person’s recovery and getting back to self-sufficiency, and hospice is a tremendously humane ministry Medicare A provides. But alone, Medicare Part A does not cover the medical care that most people need.

I recommend you seriously consider whether you need additional protection. Know your costs and coverage limitations.

Call 402-614-3389 and email us at info@omahainsurancesolutions.com for a free consultation and quote. We will confirm whether you’re covered and if additional protection is right for you.