We’ve all heard the saying that dying and paying taxes are the only two guaranteed things in life. Taxes and death have another thing in common – extensions. A CPA may instruct you on how to obtain an extension to pay certain taxes. Hospice care is to dying as a CPA is to taxes. Placing a loved one in hospice may extend a loved one’s life by weeks or months,which means you should prepare for it. In order to do so, it is important to determine how the law may affect your loved one’s eligibility, patient rights and duration of benefits for hospice care.
Hospice means a public agency or private organization primarily engaged in providing hospice care. Hospice care includes palliative care and they are used in unison by an interdisciplinary group to provide physical comfort and emotional and spiritual support to terminally ill patients and their families. Hospice care is focused on caring for the patient and not curing them.
Hospice care can be in a standalone facility, a department within a nursing home, or in a hospital. However, it is not uncommon for the terminally ill to receive hospice care in their homes. Terminally ill patients are individuals that have a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course. Hospices provide specialized care for terminally ill patients, including, but not limited to, cancer patients, HIV/AIDs patients, and those suffering from severe functional limitations and advanced cognitive impairment (e.g., Alzheimer’s, dementia).
In 2014, an estimated 1.65 million patients received hospice care services, but that number is expected to rise. During that same period, only 7.6% of the patients in hospice care were Black/African-American compared to 8.4% in 2013. By comparison, White/Caucasians (Hispanics were reported as an ethnicity and not a race) accounted for 76% of patients in hospice care in 2014 compared to 80.9% in 2013.
Paying for Hospice Care
Hospice care is covered by Medicare, Medicaid and most private insurers, but patients may also receive hospice care if they are destitute or unable to pay. States may elect to include hospice in their Medicaid programs. Medicare is by far the predominant source of payment for hospice care in the United States. As a result, Congress decided to enact the Medicare Hospice Benefit.
Hospice Care Eligibility
Hospice care is governed by the guidelines and requirements contained in the Code of Federal Regulations (See 42 CFR ch iv. Part 418) and the Sections 1102, 1861 and 1871 of the Social Security Act. The law states that in order to be eligible to elect hospice care under Medicare, an individual must be (1) entitled to Medicare Part A and (2) certified as terminally ill.
Providers determine whether you are terminally ill based on strict legal guidelines. The hospice must obtain written certification of terminal illness for each of the time periods listed below and only when they receive this certification can they submit the claim for payment. The certification requires that:
- the provider state that patient’s life expectancy is 6 months or less should the illness run its normal course;
- provide documentation to support the medical prognosis;
- a brief narrative of the provider’s clinical findings;
- a physician or nurse practitioner must attest in writing that he or she had a face-to-face encounter with the patient, including the dates of the visit; and
- all certifications must be signed and dated by the physicians and include the benefit periods for the certification or re-certification.
Duration of Hospice Care
Initial treatment at a hospice is not provided in perpetuity until an individual succumbs to their illness, but care may be extended for successive periods. Federal law requires an individual to receive hospice care for (1) an initial 90-day period; (2) a subsequent 90-day period; or (3) an unlimited number of subsequent 60-day periods. The two 90 day periods must precede the 60-day period, and before the 60-day commences a hospice physician or hospice nurse practitioner must have a face-to-face encounter with the patient. This face-to-face encounter must be repeated for each successive period thereafter in order to determine whether the individual is still eligible for hospice care.
Patient Rights for Hospice Care
An individual or their representative may elect to receive hospice care if they properly file an election statement with that hospice, and the hospice must in turn file a Notice of Election (“NOE”) with its Medicare Contractor within five calendar days in order to receive payment during that period. A medical director must consult with the patient’s attending physician before a recommendation is made about admitting the patient to hospice. In making his recommendation, the medical director must consider:
(1) the diagnosis of the terminal condition of the patient;
(2) other health conditions, whether related or unrelated to the terminal condition; and