Hospice and Palliative Care

Hospice is not a place; it is a philosophy of care.  Hospice is a Medicare benefit (more on that later) for terminally ill patients with a life span prognosis of six months or less if the disease follows its expected course. Hospice care is centered on quality of life and comfort-focused care.  An inter-professional team of providers addresses the patient's medical, physical, social, emotional, and spiritual needs. Additionally, the hospice team supports the patient’s family and caregivers through respite, bereavement and counseling services.

*Exception = Pediatric patients and Veterans receiving hospice care can have concurrent disease-directed treatment

** If a patient does not qualify for Medicare, then private insurance covers the cost and this coverage and what is offered may be different than the standard coverage via Medicare.

Hospice Levels ^{(4, 8, 9)}

There are four levels of hospice care available to patients based on their medical needs.

1.Routine “Home” Care (RHC)

• Provided wherever the patient resides (home, nursing home, assisted living)
• Includes intermittent nursing, aide, social work, and chaplain services
• The most common level of hospice

2. General Inpatient Care (GIP)

• Provided in a dedicated hospice unit which may be free-standing or within a hospital
• Specifically for uncontrolled symptoms requiring intensive management 
• Used for short-term crisis stabilization (e.g., severe pain, intractable nausea)
• Criteria must be met to qualify

3. Continuous Home Care (CHC)

• For short-term crisis management for patients receiving RHC hospice 
• Provided at home during periods of acute symptom distress (e.g., uncontrolled pain, severe dyspnea) with goal to keep patient in their home setting
• Requires a minimum of 8 hours of nursing care per 24 hours (and >50% of those hours need to be skilled nursing needs)

4. Respite Care (RC)

• Temporary relief for caregivers who are providing RHC hospice 
• Patient admitted to a hospice facility or nursing home for 5 consecutive days per benefit period
• This care transition is arranged by the hospice agency
• Goal is to prevent caregiver burnout
• A 5% co-payment can be charged to the patient by the hospice program

Medicare Hospice Benefit Coverage

1. Hospice payment ^{(1, 3, 4, 6, 14)}

• Hospice is an insurance benefit through Medicare, Medicaid or private insurance.  The Medicare Hospice Benefit (MHB) pays for most hospice care in the United States.  Most estimates are ~90% of hospice care is paid for via the MHB with Medicaid and private insurance covering the remaining ~10%. 

2. Eligibility requirements for the Medicare Hospice Benefit (MHB) ^(1,4)

All four criteria below must be met to qualify for hospice care under the Medicare Hospice Benefit, including:

• Medicare Part A eligibility
  • Medicare is for people 65 or older.
  • Some patients may qualify for Medicare before age 65 if they have a disability and receive disability payments, have end-stage-renal disease (ESRD - permanent kidney failure requiring dialysis or a transplant), or ALS (Amyotrophic Lateral Sclerosis).
• Terminal condition
  • Two physicians must certify that the patient’s prognosis is 6 months or less if the disease takes its natural course
• Patient or their surrogate choose hospice care
  • Must sign the Medicare hospice benefit election form

• Care for the patient with the terminal condition is provided by a Medicare-certified hospice program

3. Available Medicare Hospice Benefit care and services

Frequently asked questions:

• Is there a difference between what Medicare provides for hospice vs Medicaid vs private insurance? ^1,6

           Medicaid’s hospice benefits closely mirror the Medicare hospice benefit (MHB).  Private insurance plans may vary in coverage.  Some private insurances will cap the total number of days a patient can receive hospice while others may offer “per diem” plans.

• Does a patient need a cancer diagnosis to elect hospice? ^5,13

           No, a cancer diagnosis is not needed.  Cancer is a common qualifying diagnosis, but there are many other diagnoses that qualify as a terminal diagnosis (e.g., heart failure, kidney failure, neurodegenerative diseases).

• Does a patient need to be “Do Not Resuscitate/Do Not Intubate (DNR/DNI) to receive hospice care? ¹

           No.  A DNR code status cannot be used as a requirement for hospice through the Medicare Hospice Benefit (MHB).  Although this is not a requirement, DNR/DNI code status is aligned with the philosophy of hospice care and if a patient desires full code status they may not be ready for hospice care.

• Does a patient have to be in the process of dying to qualify for hospice?

          No, a patient needs to be considered “terminally ill” meaning that their life expectancy is 6 months or less if the illness runs its natural course.

• Can you be on hospice for longer than 6 months? ²

           Yes, patients are evaluated at designated time frames to determine if their prognosis remains appropriate to recertify for hospice.  Sometimes the patient’s medical decline is slower than anticipated though they continue to have an estimated prognosis of less than 6 months. 

• Can a patient be discharged from hospice? ^{2, 11, 12}

           Yes, patients can be discharged from hospice in the following situations:

            1. The patient revokes hospice care to seek curative treatments.

            2.  The patient moves out of the hospice service area and transfers to another provider.

            3. The patient is “discharged for cause” (e.g., unsafe home environment, abusive behavior).

            4. The patient is no longer terminally ill as their condition stabilizes or improves beyond the six-month prognosis (e.g., patient no longer meets eligibility criteria).