What is Hospice? È

Hospice is a special way of caring for individuals who are in the final stage of their lives due to a terminal illness. The hospice approach to care focuses on palliation and symptom management as opposed to curative care. Hospice services help patients, who are no longer seeking aggressive treatment or a medical cure, manage their terminal illness at home or in a home like environment. Hospice care addresses the physical, psychosocial, and spiritual needs of the patient and his or her family.

Where may Hospice Care be Provided? È

Although some hospice services may be provided in a facility (hospital, skilled nursing facility (SNF), or inpatient hospice facility) most services are provided in the patient's residence. The patient's residence may be a private home or apartment, boarding or rest home, assisted living facility, hospice residential or skilled nursing facility. North Carolina has a number of hospice residential facilities where a patient may receive long term residential care. It is important to realize the hospice Medicare benefit does not cover room and board in the payments made to the hospice agency. In some cases a patient may be eligible for assistance in the cost of room and board from Medicaid, if he or she qualifies.

What are the Medicare Eligibility Criteria for Hospice Care? È

In order for a patient to elect the hospice Medicare benefit the patient must be:

• Entitled to Medicare Part A,
• Terminally ill with a prognosis of six month or less if the disease runs its normal course, and
• Certified as hospice appropriate by his or her physician (initial certification requires two signatures, the patient's attending physician and the medical director of the hospice agency; re-certifications only require one physician signature, usually the medical director of the hospice agency). Certification must be received at the beginning of each benefit period.

What is Covered Under the Hospice Medicare Benefit? È

When a patient elects the hospice Medicare benefit (HMB) the hospice agency provides necessary medical and support services under a medically directed plan of care. The individualized care plan provides reasonable and necessary services in the management of the patient's terminal illness or related conditions and supportive services to the family or caregivers. Intermittent services are available 24 hours a day, seven days a week. The patient's attending physician and the hospice team develop a care plan, which is appropriate to meet the patient and his or her family's needs (medical, psychosocial, spiritual) and may include the following:

• Physician services
• Nursing care (intermittent with 24-hour on call)
• Medical appliances and supplies related to the terminal illness
• Drugs for symptom management and palliation of the terminal condition
• Short-term inpatient care for acute symptom management which may not be controlled in any other setting
• Short-term inpatient respite care (limited to five consecutive days per episode)
• Counseling services including dietary, bereavement, and spiritual
• Therapy services required in the management of the patient's terminal condition. Therapies may include physical and occupational therapy, and speech language pathology
• Ambulance services required for the proper palliation and symptom management of the patient's terminal illness. The hospice team determines an inpatient level of care is required and due to the patient's fragile condition ambulance transport is also required to carry out the needed palliative care
• Medical social services
• Aide and/or homemaker services
• Volunteer services

Although the hospice agency may arrange for some of the services to be provided by another individual or entity, the hospice agency remains the professional manager of the patient's care.

Who Pays for Hospice Services? È

Hospice services are covered under most private insurance plans, such as Blue Cross and Blue Shield of North Carolina or the State Employees' Health Plan. Also, hospice services may be covered under Medicare and Medicaid, if the patient qualifies. In addition, a patient may pay privately for hospice services. Although each hospice agency has its own policies regarding payment, Medicare certified agencies may not discontinue care to Medicare beneficiaries based on the patient's ability to pay. Agencies provide care based on the need for services rather than the ability to pay.

How is Reimbursement Made? È

Hospice agencies providing care to a Medicare patient receive reimbursement based on the level of care the patient receives. There are four levels of care, each with its own reimbursement rate. Three of the four levels of care are paid based on a daily per diem rate, the fourth level of care is paid based on an hourly rate (minimum of eight (8) hours of care required). The four levels of care are as follows:

1. Routine Care

Routine care is paid for each day the patient is under the care of the hospice and not receiving one of the other levels of care. This rate is paid without regard to the volume or intensity of routine home care services provided on a given day. The care plan includes the amount and frequency of services based on the patient and/or family's needs.

 

2. Continuous Care

Continuous care is provided when the patient is experiencing a medical crisis and requires predominantly nursing services to achieve palliation and symptom control. The hospice agency must provide a minimum of 8 hours of care within a 24-hour day period, beginning and ending at midnight. The goal of continuous care is to provide necessary medical acute care interventions at home. Although a registered nurse or licensed practical nurse provides more than half of the continuous care, homemaker or home health aide services may supplement the nursing care during the period of crisis.

 

3. Inpatient Respite Care

Inpatient respite care is arranged by the hospice agency when the family or caregivers needs relief from carrying for their loved one at home. Respite care is provided on a short-term basis, no more than 5 days per episode. Patients may be charged a coinsurance for each respite care day equal to 5% of the payment received for each respite care day.

 

4. General Inpatient Care

General inpatient care is available for pain control or acute or chronic symptom management which cannot be managed in any other setting. The short-term inpatient services must be provided by a Medicare certified facility (hospital, skilled nursing, or hospice inpatient) and must be under contract with the hospice agency. In addition to skilled nursing facilities and hospitals where short-term inpatient care may be provided, North Carolina has a number of hospice inpatient facilities.

Note: For routine and continuous care, hospice providers are reimbursed based the geographic location where the patient receives care. Agencies must report the appropriate metropolitan statistical area (MSA) code on the bill to report where routine and continuous care services were provided. This requirement does not apply to general inpatient or inpatient respite care.

How Long may Hospice Care Continue? È

The Medicare/Medicaid benefit periods apply to hospice care. There are two 90-day periods, followed by an unlimited number of 60-day periods. These periods may be used consecutively or at different times. However, while the patient is under hospice care, he or she must be hospice appropriate and be certified as terminally ill at the beginning of each benefit period.

A patient may cancel or revoke his or her hospice election at any time, for whatever reason. An agency may discharge a patient for two reasons. First, when the patient is determined to no longer be terminally ill with a prognosis of six months or less; or when the patient no longer resides in the hospice agency's defined geographic service area (usually if the hospice appropriate patient moves outside of the agency's services area, he or she transfers to another hospice rather than being discharged). When a discharge/revocation occurs, the patient's regular Medicare benefits are reinstated. However, upon discharge or revocation the remaining days in the benefit period the patient is currently in are lost.

Can A Patient Change Hospice Agencies? È

Yes, a patient may also choose to change hospice agencies once per benefit period. The agencies should coordinate care to ensure the patient's needs are met during the transfer.

How Do I Determine the Quality of Hospice Care? È

There are three mechanisms for ensuring hospice agencies meet established standards of care:

1. State Licensure

All hospice agencies that provide "hands on" care in the home must be licensed by the NC Division of Facility Services. Through license, the state ensures the agency meets or exceeds specific standards of care. All hospice agencies must meet requirements for the administration the agency, staff qualifications, patient care, and patient records.

 

2. Medicare Certification

Hospice agencies that wish to provide services and receive reimbursement under the Medicare or Medicaid hospice programs must be certified and meet federally mandated requirements, referred to as Conditions of Participation (COPs). Certified hospice agencies are subject to annual surveys to ensure the agency continues to be in compliance with all of these requirements.

 

3. Accreditation

Accreditation is a voluntary process in which a non-profit professional organization conducts a survey of the hospice agency. If the hospice agency meets the standards established by the organization, then the agency is granted "accreditation". A hospice agency may seek voluntary accreditation from one or more of the three accreditation organizations: JCAHO, ACHA, and CHAP.