Hospice: A Guide for Professionals 2016

Medicare Rights Center  The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through: Counseling and advocacy Educational programs Public policy initiatives Page 2 © 2016 Medicare Rights Center

National Council on Aging  This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging Page 3 © 2016 Medicare Rights Center

This training will cover  Medicare basics Eligibility Parts  Hospice basics Eligibility Coverage Costs Page 4 © 2016 Medicare Rights Center

Medicare basics © 2016 Medicare Rights Center Page 5

 Health insurance for people age 65+ and people who have received Social Security disability benefits for 24 months  People of all income levels are eligible  Run by the federal government but can be provided by private insurance companies that contract with the federal government What is Medicare? Page 6 © 2016 Medicare Rights Center

Medicare eligibility: Age  Who is eligible for Medicare? Those 65+ years who:  Collect or qualify to collect Social Security or Railroad Retirement benefits, or  Are a current U.S. resident, and either A U.S. citizen OR A permanent U.S. resident having lived in the U.S. for 5 continuous years before applying for Medicare  NOTE: The 5 years may be reduced if the individual qualifies for premium-free Medicare Part A Page 7 © 2016 Medicare Rights Center

Medicare eligibility: Disability  Who is eligible for Medicare? Those under 65 years who:  Have been receiving Social Security Disability Insurance (SSDI) for more than 24 months OR  Have been diagnosed with Amyotrophic Lateral Sclerosis (ALS) and have qualified for SSDI OR  Have been diagnosed with End-Stage Renal Disease (ESRD) AND Are getting dialysis treatments or have had a kidney transplant; Have applied for Medicare benefits; and Have been deemed eligible for SSDI, railroad retirement benefits, or are otherwise considered to be fully insured by Social Security Page 8 © 2016 Medicare Rights Center

Parts of Medicare  Medicare benefits are administered through three parts Part A – Hospital/Inpatient benefits Part B – Doctor/Outpatient benefits Part D – Prescription drug benefit  Added 2006  What happened to Part C? Private health plans (e.g., HMO, PPO)  Way to get Parts A, B, and usually D through one private plan  Known as Medicare Advantage  Not a separate benefit  May cover services not covered by Parts A and B (i.e. Original Medicare), such as vision and dental care © 2016 Medicare Rights Center Page 9

Hospice basics © 2016 Medicare Rights Center Page 10

What is hospice care?  Program of end-of-life pain management and comfort care  Hospice goal is to help beneficiaries live comfortably, not to cure an illness  Hospice focuses on care that treats the whole person, or holistic care © 2016 Medicare Rights Center Page 11

Hospice care  After electing hospice, an individual’s care will be managed by a specially trained team of professionals and caregivers Team addresses beneficiary’s physical, emotional, social, and spiritual needs  Beneficiaries receive care in their home A doctor and nurse will be available on call 24 hours/day, seven days/week © 2016 Medicare Rights Center Page 12

Hospice eligibility  To elect hospice, an individual must must: Have Part A Have a hospice doctor certify that they have a terminal illness* Sign a statement electing to have Medicare pay for palliative care (pain management) Receive care from a Medicare-certified hospice agency  If a beneficiary elects hospice, Medicare will no longer pay for curative care related to their terminal illness Can still receive curative treatment for unrelated conditions** © 2016 Medicare Rights Center Page 13

Hospice and Medicare Advantage  Hospice is always covered by Original Medicare After electing hospice, those with Medicare Advantage (MA) Plans will be covered by Original Medicare for all care related to their terminal illness MA Plan will continue to cover care unrelated to the terminal illness or its conditions  Beneficiaries must continue to follow their plan’s rules for any care covered by their MA Plan This includes seeing in-network providers and/or paying plan copays  MA Plan will continue to cover any additional benefits it provides, such as vision or dental © 2016 Medicare Rights Center Page 14

The benefit period  Medicare will cover hospice care for two 90-day benefit periods, or six months  Afterwards, an individual is allowed an unlimited amount of 60-day (two-month) benefit periods At the start of each new benefit period, a hospice doctor must recertify that beneficiary has a life expectancy of six months or less © 2016 Medicare Rights Center Page 15

Hospice coverage and costs © 2016 Medicare Rights Center Page 16

What hospice covers  Depending on the terminal illness and related conditions, hospice care can include any of the following: Doctor services Nursing care Durable medical equipment (DME) Medical supplies (like bandages and catheters) Prescription drugs Hospice aide and homemaker services Physical, occupational, and/or speech therapy Social work services Dietary counseling Grief and loss counseling (for the beneficiary and immediate family members) Short-term inpatient care (for pain and symptom management) Short-term respite care Other services recommended by hospice team © 2016 Medicare Rights Center Page 17

Respite care  Allows beneficiary’s caregiver to rest while beneficiary receives care in a Medicare- approved facility Can be a hospice inpatient facility, hospital, or nursing home Beneficiary can stay up to five days each time they get respite care* Respite care can only be provided on an occasional basis  Care received at facility must be non-curative comfort care © 2016 Medicare Rights Center Page 18

Hospice aides and homemaker services  Hospice aides may provide personal care services, for example: Changing the bed Light cleaning and laundering Generally maintaining a safe and sanitary environment for beneficiary  Hospice aides are overseen by registered nurse on the beneficiary’s hospice team © 2016 Medicare Rights Center Page 19

Short-term inpatient stays  Hospice can include inpatient care at a hospital, SNF, or hospice inpatient facility Patient’s medical condition must call for a short-term stay for pain control or acute or chronic symptom management Only covered if care cannot feasibly be provided in another setting All care received must comply with plan of care © 2016 Medicare Rights Center Page 20

Counseling services  Provided to beneficiary and family members, or others caring for the beneficiary at home  Counseling can: Train family members/caregivers to provide care Help beneficiary and family members come to terms with the beneficiary’s terminal condition  Under certain conditions, dietary counseling is also available © 2016 Medicare Rights Center Page 21

Bereavement services  Hospice covers bereavement counseling for beneficiary and their immediate family Emotional, psychosocial, and spiritual support and services Available after hospice has been elected Family members may continue to receive counseling up to a year after the beneficiary passes © 2016 Medicare Rights Center Page 22

Continuous home care (CHC)  In crisis situation, if beneficiary’s caregiver is unwilling or unable to continue providing care, hospice agency may decide to provide CHC A hospice agency can only provide CHC to a beneficiary if their caregiver was providing skilled care that maintained palliation*  Hospice will provide a minimum of eight hours of nursing each 24-hour day so that skilled care continues to be provided © 2016 Medicare Rights Center Page 23

Hospice costs  After electing hospice, beneficiary must continue paying their deductible and monthly premiums*  Hospice benefit should cover all care related to terminal illness Remember: if beneficiary has an MA Plan, Original Medicare still pays for any hospice-related care  Additional costs include: $5 copay for pain and symptom management prescription drugs 5% of the cost for inpatient respite care Copays and coinsurances for any care received unrelated to terminal illness or its conditions © 2016 Medicare Rights Center Page 24

Medigap coverage under hospice  Some beneficiaries may have purchased a supplemental insurance policy, or Medigap Medigaps cover cost-sharing for Original Medicare beneficiaries Beneficiary must pay monthly premium for Medigap  Medigap will cover previously discussed costs for prescription drugs and respite care  Medigap will also continue to cover costs for care unrelated to terminal illness and its conditions © 2016 Medicare Rights Center Page 25

What hospice doesn’t cover  Once an individual has elected hospice, Medicare will no longer cover: Curative care for the terminal illness or any related conditions Prescription drugs (except for pain and symptom management) Care for the terminal illness and related conditions from providers other than the hospice medical team* Hospital outpatient care, inpatient care, or ambulance transportation, unless it’s unrelated to the terminal illness or arranged by the hospice team  Medicare does not cover room and board © 2016 Medicare Rights Center Page 26

Beneficiary hospice rights © 2016 Medicare Rights Center Page 27

Rights after electing hospice  Getting hospice care does not change a beneficiary’s rights, including: Right to choose Medicare doctors and related providers Right to file complaints Right to appeal  Beneficiaries also have the right to: End hospice care at any time Appeal their hospice doctor’s decision to end their hospice Change their hospice agency Page 28 © 2016 Medicare Rights Center

Ending hospice  Beneficiaries have the right to stop hospice at any time Can elect to return to curative treatment  Beneficiaries should speak with their doctor if interested in stopping Beneficiary will have to sign a form that includes the date their hospice care will end Once hospice care has ended, beneficiary will receive their Medicare benefits however they did before hospice, either through Original Medicare or a Medicare Advantage Plan © 2016 Medicare Rights Center Page 29

Appeal rights  At the start of each new benefit period, a doctor must recertify that beneficiary has a life expectancy of six months or less  If doctor declares beneficiary to be no longer eligible for hospice, beneficiary can request review of their case Doctor is required to give beneficiary a notice explaining their right to an expedited appeal, including instructions for how to appeal © 2016 Medicare Rights Center Page 30

Changing hospice agencies  Beneficiaries have right to change their hospice agency once each benefit period To change agencies, beneficiary must sign a statement naming the hospice agency they plan to receive care from, their previous hospice agency, and the effective date of the change The statement should be filed at both hospice agencies © 2016 Medicare Rights Center Page 31

Selecting an attending physician  Beneficiaries can choose their regular doctor or nurse practitioner to be their attending physician This allows beneficiary to continue seeing their own doctor after electing hospice care, if they wish This doctor will be included in in the hospice team and supervise care Beneficiaries can select a new attending physician by filing a signed statement with their hospice agency © 2016 Medicare Rights Center Page 32

For more information and help  Local State Health Insurance Assistance Program (SHIP)  Social Security Administration  Medicare 800-MEDICARE ( )  Medicare Rights Center  National Council on Aging © 2016 Medicare Rights Center Page 33

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