What Is Hospice, and When Can Someone Get It Under Medicare?

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What is hospice, and when can someone get it under Medicare?

What is hospice? Hospice is an alternative to regular medical care for people in the final months of life. Instead of continuing to try curing or delaying the fatal disease or condition, hospice ends treatment altogether. Instead, its goal is to control pain and other symptoms and make the patient's last stretch of life as comfortable as possible. Hospice can result in a significant improvement in the patient's quality of life, with a focus on her as a person rather than on her disease.

If someone chooses hospice, it means she can leave the hospital or nursing facility and spend her last weeks or months in her own home or in a family member's. Hospice caregivers are specially trained to carefully calibrate pain medication and other symptom relief so that a patient is as comfortable as possible and able to appreciate the time she has left with loved ones.

Because hospice caregivers work wherever a patient is staying, they can also bring relief to you or others who are providing most of her daily care. Hospice can even move a patient into a special hospice facility for a few days of what is called "respite care," giving you and other caregivers a short break from your duties.

When and how can a patient choose Medicare hospice? If she's enrolled in Medicare Part A and meets certain conditions, she may choose to receive Medicare-covered hospice care, which covers nearly the full cost. To qualify, her treating physician must certify that she has a terminal illness and that she probably has less than six months to live.

Of course, doctors usually can't predict exactly how long someone will live. And they are sometimes reluctant to say what they think about life expectancy. So Medicare builds in a protection in case the prediction proves wrong -- if a patient chooses hospice but lives longer than six months, hospice can be continued as long as she needs it. Or, if her condition stabilizes or even improves, she can give up hospice and return to regular Medicare coverage.

The other condition is that she must formally give up any further treatment of her terminal illness or condition. This "giving up" may be very difficult, both for caregivers and the patient. But recognizing the futility of further treatment is an essential part of the transition to hospice and is necessary for hospice to bring maximum relief and comfort to her.

Does choosing hospice mean someone gives up all medical treatment? By choosing hospice, a patient gives up all treatment of her terminal illness or condition . But that doesn't mean she gives up treatment -- and Medicare coverage -- for any other illness or condition that might trouble her during her last months of life. If she gets the flu or has trouble with her back or has any other medical problem, she can receive treatment from her doctors and have it covered by Medicare Part B in the normal way.

Is choosing Medicare hospice a decision a person is stuck with? There are several reasons why someone eventually might want to discontinue hospice care. She might simply change her mind about giving up treatment, or her doctors might advise her about a new treatment. Her condition might stabilize or even improve, changing the doctor's prognosis about how long she has to live. Or for some reason she might not like hospice care and prefer to return to regular Medicare coverage (which still allows her to refuse any specific treatment she doesn't want). For any of these reasons -- or for no reason at all -- a patient can end hospice care at any time and return to regular Medicare coverage.

What services does Medicare hospice offer?

Hospice is provided by a Medicare-certified agency that can offer a variety of services. These are carefully coordinated within a plan of care developed by the hospice agency in cooperation with the patient's doctor.

Do services include personnel and equipment?

The specific services provided depend on the patient's particular needs and preferences and can include:

  • Medical personnel. A hospice physician, in consultation with a patient's doctor, develops an initial hospice care plan. After the plan is in place, you and the person you're caring for won't see much of either doctor, except for problems other personnel cannot handle. Special hospice nurses are often involved in the initial period of adjustment to hospice care, along with a physical therapist, and a nurse is likely to oversee ongoing care.
  • Personal aides. Most of the care someone receives through hospice comes from specially trained hospice aides. Aides monitor her symptoms and perform tasks to make her comfortable, including administering pain relief and other medications. They can also help with simple household tasks, though they don't provide general housekeeping services. An aide comes as often as needed, and toward the end, an aide may spend several hours every day with a patient.
  • Counseling. Hospice makes various kinds of counseling available, not only to a patient but also to caregivers and family members. A social worker may be available to help with arrangements and paperwork regarding financial and estate matters and end-of-life decisions. Counselors and clergy are also available to help everyone -- patient and caregivers -- deal with emotional issues.
  • Medication and equipment. Hospice provides a patient with any drug she may need -- for pain and other symptom control, sleep, mobility, digestion -- to keep her as comfortable as possible. Hospice provides the medications directly, without the need to go to the pharmacy, get a special prescription, or use insurance coverage. The same is true for medical equipment such as a hospital bed, wheelchair, walker, or the like.
Does hospice provide any relief for caregivers?

Hospice attends not only to a patient but also to the needs of caregivers and family. The physical and emotional toll of caring for someone can become enormous, especially if only one or two people are doing most of the round-the-clock care giving. A special feature of hospice, called "respite care," gives caregivers a break by moving the patient to a special hospice facility where, for up to five days, she gets 24-hour daily care. There can be more than one of these respite periods during a patient's time with hospice. Respite care does not happen automatically; the caregiver or the patient's family must specifically request it from the hospice agency.

How does Medicare hospice actually work once someone chooses it?

If a patient and her doctor agree that hospice is the right choice, you can help her choose a hospice agency. Her doctor or a hospital or nursing facility discharge planner may recommend one. If the patient lives in a senior residence or an assisted living or long-term care facility, the facility can recommend one or more hospice agencies. You can also check our local guide to find out about all nearby hospice agencies or by contacting your state's hospice association; you can get the number from the Hospice Association of America .

  • Once a patient chooses a hospice agency, she must formally enroll in it. The agency handles all the paperwork. If she isn't physically or mentally able to give consent, enrollment must be made by the person who has power of attorney or other authority over the patient's healthcare decisions.
  • The hospice agency begins by setting up a care plan. This includes discussions with the patient and with any family members or others who will be regularly providing her with full-time care. It also involves a visit wherever she'll be staying. There's usually a flurry of activity when the hospice agency first gets involved, with various hospice staff visiting the patient and assessing her needs. Then a regular routine is established, with one or more aides visiting on a schedule. This schedule changes as the patient's needs change.
  • It's important to speak up about things you like and don't like about the care a patient is receiving, including asking the agency to send (or not send) one aide or another if the patient develops a strong preference. You may even switch to another agency altogether if you or the person you're caring for isn't satisfied with the hospice care she's receiving.
  • A patient's need for hospice is evaluated after 90 days to determine if it's still appropriate. It's evaluated again at the end of another 90 days and can be continued in 60-day segments after that. Although intended only for a six-month period, hospice often lasts longer than that because many people live longer than the original six-month prognosis.

How do hospice payments and medical coverage work?

Does a person have to pay anything for Medicare hospice?

Medicare-sponsored hospice provides very intensive, high-quality care almost for free. Medicare pays the hospice agency directly for a patient's care. The patient is responsible only for up to five dollars for each prescription medication provided by hospice and a copayment of 5 percent of what Medicare pays for the days she's a hospice inpatient while caregivers take advantage of respite care .

How does hospice care affect any other medical insurance coverage a patient has?

Even if someone enrolls in hospice , she should keep up her premium payments for Medicare Part B medical insurance and her medigap insurance policy , if she has one. If she's enrolled in a Part C Medicare Advantage plan instead, she should keep paying that premium. That's because she'll want to continue coverage for other medical needs she may have while she's in hospice. And she won't want any interruption in coverage if she decides to leave hospice for any reason.

Joseph L. Matthews

Joseph Matthews is an attorney and the author of numerous books, including Social Security, Medicare, and Government Pensions, Long-Term Care: How to Plan and Pay for It; How to Win Your Personal Injury Claim; and The Lawyer Who Blew up His Desk. See full bio