HOSPICE BENEFIT COVER

• Doctors.
• Nurses or Nurse Practitioners.
• Social Workers.
• Physical & Occupational Therapists.
• Speech – Language Pathologist.
• Hospice Aides.
• Volunteers.

• Drug for Symptoms Control or Pain Relief.
• Bereavement Counseling for you and your family.
• Durable Medical Equipment.
• Medical Supplies/ Incontinence Supplies.
• Dietary Counseling.
• Short-term inpatient care.
• Short-term respite care.

HOSPICE ELIGIBILITY REQUIREMENTS

As a home health patient, you have the privacy rights listed below:

• Patient has been diagnosed with a life-limiting condition with a prognosis of six months or less if their disease runs its normal course.
• Frequent hospitalizations in the past six months.
• Progressive weight loss (taking into consideration edema weight).
• Increasing weakness, fatigue, and somnolence.
• A change in cognitive and functional abilities.
• Compromised Activities of Daily Living (ADLs) such as eating, bathing, dressing, toileting, transferring/ walking, and continence.
• Deteriorating mental abilities.
• Recurrent infections.
• Skin breakdown.
• Specific decline in condition.

ELIGIBILITY KEY POINTS

• Patients must be more likely than not to die in less than six months. One does not need to certain they will die in less than six months.
• It is necessary to know whether the individual patient will die in six months or less. The attending physician and the hospice medical director/ hospice physician are asked to make a decision about whether patients who present as the patient in question have a six months prognosis if the illness runs its normal course.

FINANCIAL REQUIREMENTS FOR HOSPICE CARE

MEDICAID HOSPICE BENEFITS

Medicaid is a jointly funded, federal, and state program that provides free or low-cost health insurance coverage to low-income families, pregnant women, the disabled, and the elderly. Nevada Medicaid participants are eligible to receive hospice care when they have been diagnosed with a terminal illness with a medical prognosis of fewer 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.

NEVADA MEDICAID PROGRAM REQUIRE THE FOLLOWING:

• Certification of terminal illness by the patient’s physician.
• The patient must agree they are accepting hospice care by completing an electronic form.
• The 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.

THE MEDICAID HOSPICE BENEFIT COVERS SERVICES PROVIDED BY A SKILLED HOSPICE TEAM TO MEET YOUR PHYSICAL, PSYCHOLOGICAL, EMOTIONAL, AND SPIRITUAL NEEDS. THESE INCLUDES:

• 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 work alongside their family and physicians to provide the care and comfort they need for the highest possible quality of life.

MEDICAID COVERAGE RESTRICTIONS

Curative Treatment: The Medicaid hospice benefit requires patients to 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 of the patient reside 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.

MEDICARE HOSPICE ELIGIBILITY CRITERIA

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 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 programs 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 them an unlimited number of 60-day benefit periods. After each benefit period, the patient must be certified to ensure they continue to meet the qualifications for hospice care.

MEDICARE HOSPICE COVERAGE

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

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.

HOSPICE 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 cost 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 board changes 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.

PRIVATE INSURANCE HOSPICE COVERAGE

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.