Hospice programs work closely with patients and families to identify reimbursement options. Care is provided regardless of the patient’s ability to pay.
The Medicare Hospice Benefit
Hospice care provided by Medicare certified hospice programs is covered by the Medicare Hospice Benefit (Part A). Physician services can continue to be billed through Medicare Part B.
Medicare beneficiaries who choose hospice care receive non-curative medical and support services for their terminal illness. Home care may be provided along with necessary inpatient care and a variety of services not otherwise covered by Medicare.
Eligibility For Use
Medicare coverage for hospice care is available only if
- the patient is eligible for Medicare Part A;
- the patient’s physician and the hospice Medical Director certify that the patient is terminally ill with a life expectancy of six months or less;
- the patient signs a statement choosing hospice care instead of standard Medicare benefits for the terminal illness; and
- the patient receives care from a Medicare-certified hospice program.
Length of Benefit
When a Medicare beneficiary elects to receive hospice care they are entitled to receive a maximum of two 90-day benefit periods, followed by a 60-day period, and when necessary, an extended period of indefinite duration. The benefit period may be used consecutively or at intervals. The patient must be certified as terminally ill at the beginning of each period.
Services Not Covered
All services required for the management of the terminal illness must be provided by or through the hospice. When a Medicare beneficiary chooses hospice care, Medicare will not pay for:
- active treatment of the terminal illness that is not for symptom management and pain control
- care provided by another hospice that was not arranged by the patient’s hospice
- care from another provider that duplicates care the hospice is required to furnish
Availability of other Medicare Benefits
When a Medicare beneficiary chooses hospice care, he or she gives up the right to standard Medicare benefits for the management of the terminal illness. A patient can use all appropriate Medicare Part A and B benefits for the treatment of health problems unrelated to the terminal illness (U.S. Department of Health & Human Services Health Care Financing Administration, 1995).
Reimbursment for Physicians under Medicare
The attending physician is the physician designated by the patient to have the most significant role in his or her care. The attending physician continues to bill Medicare Part B for professional services home, inpatient, or nursing home visits in the usual manner, independent of the Hospice benefit. Medications, laboratory tests, and other non-physician services required for the management of the terminal illness are paid for by the hospice program through the hospice benefit.
Attending physicians can bill for care plan oversight for hospice patients. Payment is available for one physician per month for oversight supervision involving 30 or more minutes of the physician’s time per month.
Payment under CPT code 99375 encompasses significantly complex medical management requiring the integration of new information into the plan of care or adjustments in medical therapy furnished by the physician. It identifies the coordination of care among practitioners as care plan oversight services. This excludes telephone calls to patients and family members (Federal Register, 1994).
Care plan oversight includes the following physician activities:
- development/revision of care plans
- review of subsequent reports of patient status and related laboratory studies
- coordination and communication (including the telephone calls) with other health care professionals involved in the patient’s care (excluding telephone calls to patients and family members)
- adjustment and integration of medical treatments.
Other Payer Sources
Hospice Medicaid/Minnesotacare Benefit
The Medical Assistance and MinnesotaCare Hospice Benefit follows the Medicare Hospice Benefit.
Private Insurance Coverage
The majority of commercial insurance providers cover hospice care either through a specific hospice benefit or through a home care benefit. Several providers have recently developed or are developing hospice benefits that reimburse on a per diem basis (like Medicare). When there is not a specific hospice benefit, insurance companies often reimburse through a home health care benefit. Patients should be encouraged to contact their insurance carrier about coverage for hospice.
Non-Medicare-Certified Hospice Programs
Services from hospices that are not Medicare certified can be billed under regular Medicare Part A. Many of the hospice services are provided free of charge, and the patient can access grants to cover billable services.