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Medicare Coverage of Hospice Care, Palliative Care and Skilled Nursing Care

hospice, medicare coverage of hospice respite care, will medicare cover hospice care

I cannot say enough about Hospice.  They helped my family get through end of life care with love and tenderness.  There are other organizations that provide similar care so I cannot presume hospice is the only organization to provide services with the same personal touch.  I can only make recommendations based on my experience.  And for us, they were absolutely wonderful.  Even better, in most areas, if you do not have insurance coverage, hospice is typically non-profit.  This means you can get the  same quality care with or without any type of insurance.  Call hospice services in your area to determine their non-profit status as applicable to your personal situation.  Check your long term care policy for respite and hospice coverage.  Information regarding Medicare hospice benefit is below.

Hospice Care

Medicare Part A covers hospice care if you meet all of the following conditions:

  • You are eligible for Medicare Part A.
  • Your doctor certifies that you’re terminally ill and are expected to have less than 6 months to live.
  • You accept palliative care (for comfort) instead of care to cure your illness.
  • You sign a statement choosing hospice care instead of routine Medicare-covered benefits for your terminal illness.

Medicare will still pay for covered benefits for any health problems that are not related to your terminal illness.

In a Medicare-approved hospice, nurse practitioners are not permitted to certify the patient’s terminal diagnosis, but after a doctor certifies the diagnosis, the nurse practitioner can serve in place of an attending doctor. They stay in regular contact with the doctor for your overall treatment.  You can continue to get hospice care as long as the hospice medical director or hospice doctor re-certifies that you are terminally ill.

Hospice care is usually given in your home. However, some areas offer hospice services in collaboration with a local hospital or other care facility.  In these instances, location of care is dependent on personal preference.  Care includes the following services when your doctor includes them in the plan of care for palliative care (for comfort) for the terminal illness and related conditions:

  • Physician and nursing services
  • Social work services
  • Counseling services
  • Hospice aide or homemaker services
  • Physical, occupational, or speech language pathology therapy services
  • Drugs and medications for pain or other symptoms
  • Medical supplies and durable medical equipment
  • Short-term inpatient care for symptom relief, or for respite care*
  • Any other services normally covered by Medicare to provide care for the terminal illness and related conditions

Respite care is inpatient care given to a hospice patient so that the usual caregiver can rest. You can stay in a Medicare-approved facility, such as a hospice facility, hospital, or nursing home, up to 5 days each time you get respite care.

In 2011, you pay $0 for hospice care. You may need to pay a copayment of up to $5 per prescription for outpatient prescription drugs for symptom control or pain relief. Medicare does not cover room and board when you get hospice care in your home or another facility where you live (like a nursing home). If your attending doctor is not employed by the hospice, you pay your usual Part B deductible and copayment for his or her services.  Ensure coverage of hospice care has not changed by visiting Medicare.gov.

If the hospice staff determines that you need short-term inpatient care in a hospice facility, hospital, or nursing home, or if your caregiver needs a short period of respite, Medicare covers the costs for room and board. You pay 5% of the Medicare-approved amount for inpatient respite care.

Find home care and hospice providers in your area at the National Database.

Skilled Nursing Care

nurjsin home, nursing care, skilled nursing care, medicare coverage of nursing careYour desire to stay at home may be impacted by unexpected illness, condition or inability to live independently any longer. In this case, assisted living or skilled nursing care may be required. While these living choices can be very expensive, some coverage may be available. This also true if temporary skilled nursing care is needed following a fall, medical procedure or other situation where your physical capabilities are expected to improve.

People with Medicare are covered if they meet all of the below conditions.

  • You have Part A and have days left in your benefit period.
  • You have a qualifying hospital stay.
  • Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or rehabilitation staff. If you’re in the skilled nursing facility for rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.
  • You get these skilled services in a facility that is certified by Medicare.
  • You need these skilled services for a medical condition that was either:
    • A hospital-related medical condition.
    • A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.

Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your stay. Find out if you’re an inpatient or an outpatient.

If you refuse your daily skilled care or therapy, you may lose your Medicare coverage. If your condition won’t allow you to get skilled care (for instance if you get the flu), you may be able to continue to get Medicare coverage temporarily.

Medicare covers up to 100 days of care in a skilled nursing facility for each benefit period if all of Medicare’s requirements are met, including your need of daily skilled nursing care with 3 days of prior hospitalization.

Medicare pays 100% of the first 20 days of a covered stay. A copayment of $152 per day (in 2014) is required for days 21-100 if Medicare approves your stay.

Medicare covers up to 100 home health visits per period of illness following a hospital stay. Additional home health benefits are available under Part B. Home health visits under both Parts A and B must meet the following conditions:

  • A physician has certified you as homebound
  • Intermittent skilled nursing or therapy services are required
  • Services are provided by a Medicare-certified home health agency
  • Hospice care is available for terminally ill patients. The goal of hospice care is to keep the patient as comfortable as possible. It does not provide treatment for the terminal illness.

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part A covers skilled nursing care in a skilled nursing facility under certain conditions for a limited time.

Medicare-covered services include, but aren’t limited to:

  • Semi-private room (a room you share with other patients)
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy*
  • Speech-language pathology services*
  • Medical social services
  • Medications
  • Medical supplies and equipment used in the facility
  • Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that are not available at the facility
  • Dietary counseling

If you’re in one of these facilities but must be readmitted to the hospital, there’s no guarantee that a bed will be available for you at the same facility if you need more skilled care after your hospital stay. Ask them if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.

Medicare covers swing bed services in certain hospitals, like a critical access hospital, when there’s not a nursing home nearby to provide the kind of care someone needs after being in a hospital. These services are covered under a “swing-bed” agreement, under which the facility can “swing” its beds and provide either acute hospital or skilled nursing level care, as needed. When swing-beds are used to furnish skilled nursing level care, the same coverage and cost-sharing rules apply as though the services were furnished in a skilled nursing facility.

If you stop getting skilled care, or leave the facility altogether, your coverage may be affected depending on how long your break in skilled care lasts.

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional skilled facility care. The new hospital stay does not need to be for the same condition that you were treated for during your previous stay.

If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your benefits. This means that the maximum coverage available would be up to 100 days of skilled nursing facility benefits.

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs.

If you do not have enough income to cover deductibles, you may qualify for Medicaid. All states offer a variety of Medicaid programs and several can help people with Medicare. If you qualify for a Medicaid program (no matter which one), Medicaid can help pay for costs and services that Medicare does not cover. Medicare is the primary payer and Medicaid pays second.

For services that both Medicare and Medicaid can cover (such as doctors’ visits, hospital care, home care and skilled nursing facility care), Medicare will pay first and Medicaid will pay second, by covering your remaining costs, such as the Medicare coinsurances and copayments.

In many cases if you have Medicaid, you will automatically be enrolled in a Medicare Savings Program. Also run through Medicaid, they will offer additional assistance by paying your Medicare Part B premium, deductibles, coinsurances and copayments. You will need to meet the guidelines for eligibility in your state.

If you have Medicare, Medicaid and Medicare Savings Program, you should be able to go to any doctor or provider who takes Medicare, Medicaid or is in your Medicare private health plan’s network without having to pay the Medicare coinsurances or deductibles. You may still have to pay the Medicaid copayment for the service, depending on the rules in your state. However, if you go to see a provider who takes Medicare and Medicaid, the provider is most likely to bill correctly. If your provider bills you incorrectly, you should call your local State Health Insurance Assistance Program.

Medicaid can cover much more long-term care than Medicare does. Medicare requirements for coverage of long-term care services, such as home care and skilled nursing facility (nursing home) services, are generally stricter than Medicaid’s and the coverage itself is much more limited.

If you qualify for Medicare-covered skilled nursing facility care or home care, Medicaid will pay second to cover your Medicare coinsurances, copayments and deductibles. If your Medicare skilled nursing facility coverage ends (Medicare covers a limited number of days) or if your home health care is not comprehensive enough (Medicare generally covers a limited amount per week), Medicaid can cover additional services. If you do not qualify for Medicare coverage of long-term services at all, Medicaid may cover it for you.

Medicaid will also pay for medical services not covered at all by Medicare as long as they are covered by Medicaid. Such services may include routine dental services and transportation to and from doctors’ appointments.

Medicaid can help cover your prescription drug costs. If you have Medicare and qualify for a Medicaid program, you then automatically qualify for Extra Help, the federal program that helps with the cost of Medicare prescription drug coverage (Part D). Note: If you will lose your retiree or union coverage by enrolling in a Medicare private drug plan, you may not have to take Medicare drug coverage. Contact your Medicaid office to find out.

Depending on your state, Medicaid may wrap around your Medicare drug plan to cover drugs or pick up costs that Medicare does not.

Some states may require people with Medicare and Medicaid to enroll in a Medicaid private health plan. Your state may encourage you to enroll in a Medicare private health plan that your Medicaid private health plan is designed to work with. But even if you are required to enroll in a Medicaid private health plan in your state, you cannot be required to enroll in a Medicare private health plan. Check with your local Medicaid office to learn more about your health plan options. To find out the exact Medicaid programs you may be eligible for, you should contact your local Medicaid office and speak to a counselor. Financial eligibility guidelines and covered services vary greatly from state to state and from program to program. Be aware that you may be able to have higher income than general eligibility guidelines suggest because certain income may not be counted, or you may be able to qualify another way—for example, by spending down your income on medical expenses.

Eligibility is determined by resources, income and medical necessity. A spouse or partner’s home and/or financial assets may be in jeopardy and/or Medicaid coverage of skill nursing facility care denied if either of your incomes or joint asset values are too high. The spouse who remains at home or the community spouse may keep a minimum monthly case allowance of $1,823. Depending on allowable expenses this amount can increase to a maximum of $2739 per month. The maximum cash resources for the community spouse cannot exceed $109,560. Resources are defined as cash money and any other personal or real property that person or couple owns and may include, but are not limited to: checking accounts, stocks and bonds, certificates of deposit, automobiles, land, burial reserves, life insurance policies, and savings accounts.

Once qualified, Medicaid assists eligible patients with the monthly cost in a nursing home for both skilled and intermediate care. The patient’s monthly income minus $40 per month for personal use, is applied to the monthly cost of the nursing facility. Medicaid adds to the amount the patient has as income, to reach the total amount required by the nursing home.

Make sure there is no change to coverage of Skilled Nursing Facilities by going to Medicare.gov.

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