Patient elects hospice benefit; 4. Care is specified in the hospice plan of care; and 5. Hospice program is Medicare-certified. Under Medicare, there are currently two methods of appeal available for denials of hospice care. The appeals are fraught with confusion and bureaucratic complications.
To make matters worse, the two systems are not clearly named or demarcated. The right to an expedited appeal became effective on July 1, Providers are financially liable for continued services until two days after the beneficiary receives valid notice or until the service termination date specified on the notice, whichever is later.
Providers sometimes inappropriately believe that since the beneficiary is still getting care from the same organization, they do not have to issue the standard notice regarding expedited appeal. If beneficiaries make untimely requests, they lose financial liability protections and the guarantee of a quick decision.
The provider can charge for the cost of duplicating documents. Unfortunately, beneficiaries are never told they have the right to review the documents. In the event that a beneficiary does request access to the medical records, the provider must accommodate the request by no later than close of business of the first day after the material is requested. In addition, the expedited appeal system is not synchronized with the standardized appeal system. Unless the beneficiary requests an extended period, the QIC must render a decision within 72 hours of receipt of the request for an expedited reconsideration, and any medical or other records needed for such reconsideration.
The QIO must accommodate the request no later than close of business of the first day after the material is requested. Making the system particularly confusing is the fact that hospice beneficiaries not only have a right to an expedited appeal, but also a right to standard appeals. Standard appeals review not whether care should have been terminated, but whether rendered and billed care should be paid for by Medicare.
The following things related to hospice care are covered, according to Medicare :. All items and services needed for pain relief and symptom management. Medical, nursing and social services. Durable medical equipment for pain relief and managing symptoms. Other covered services needed to manage pain and additional symptoms, and spiritual and grief counseling for you and family members.
In addition to you and your family members, your hospice care team may include some or all of the following:. Physical and occupational therapists. Once your hospice benefit has begun, Medicare will not cover any of the following:. Curative treatment: Any treatment meant to cure your terminal illness or any related conditions. Curative drugs: Prescription drugs meant to cure your condition. Once you have a hospice provider, you must get care arranged by them. If your hospice team decides you need a short inpatient or respite care stay, Medicare will cover the costs, although you may owe a small copayment.
Care received as a hospital outpatient such as in an ER , as a hospital inpatient or ambulance transport. If you have Original Medicare, you must find a hospice provider that is Medicare-approved. You can do that here , as well as asking your doctor, your state hospice organization or state health department. If you have Medicare Advantage , your plan can help you find a local hospice provider. The hospice benefit is meant to allow you and your family to stay together at home unless you require care at an inpatient facility.
If you need inpatient care at a hospital, the arrangements must be made by your hospice provider — otherwise you might be responsible for the costs of your hospital stay [4]. At the start of every benefit period after the first, you must be recertified as terminally ill. Once your hospice benefit begins, everything you need will be covered by Original Medicare, even if you decide to stay in your Medicare Advantage plan or another Medicare health plan.
You do have to continue paying the premiums. Get more information below about some of the major Medicare Advantage providers. These insurers offer plans in most states. The plans you can choose from will depend on your ZIP code and county.
Aetna Medicare Advantage plans. Cigna Medicare Advantage plans. Humana Medicare Advantage plans. When a Medicare beneficiary enters hospice, the hospice benefits are typically provided via Original Medicare , even if the beneficiary had previously been enrolled in Medicare Advantage. But as of , CMS is piloting a program that allows Medicare Advantage plans to include hospice benefits. To qualify for hospice benefits, a patient must be eligible for Medicare Part A , and a doctor must certify that the patient is terminally ill and has six months or less to live.
Medicare-approved programs usually provide care in your home or other facility where you live, such as a nursing home or, in some cases, hospitals. Medicare will also cover respite care , which is a short-term stay at a qualified hospice facility.
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