Diving deeper into Medicare requirements

Published 9:42 am Monday, July 31, 2023

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Many questions have been asked about last week’s column concerning the Medicare requirement that two physicians determine a patient has “six months or less” to live. The definition of terminal illness is a life expectancy of “six months or less,” if the disease runs its normal course. Therefore, in today’s column, we will expound upon this statement. Because Medicare acknowledges estimating someone’s life expectancy isn’t an exact science, the hospice benefit has been designed with this principle in mind. Hospice care is broken down into benefit periods: two 90-day periods, followed by unlimited 60-day periods. So, a patient receives hospice care for two 90-day benefit periods (incidentally added together equals six months). Prior to the unlimited 60-periods, a patient is seen by the hospice Medical Director or Nurse Practitioner to determine if the patient still meets Medicare criteria, and if confirmed, the patient is recertified by the Hospice team.

Vickie Wacaster, Patient and Hospice Advocate with Aveanna Hospice (formerly Comfort Care Hospice)

Concerning the six-month time frame, I believe that when Medicare adopted the hospice benefit, they needed a way to monitor its use and ensure people were using the benefit as intended and not misusing the benefit. Consequently, I have researched, and cannot find why Medicare used a six-month rule instead of a 3-month rule, a 9-month, or such. Nonetheless, without a six-month rule and terminal illness rule, we would all likely qualify as, from the moment we are born, we are facing the opposite end of the spectrum of life.

Hospice care is available for terminally ill patients who are no longer under treatment for a cure and have a limited life expectancy. The patient’s primary physician usually initiates the referral process; case managers, hospital or nursing home personnel, clergy members, family members, or other healthcare professionals may also refer patients. However, an order from a physician for evaluation and admission is required. For that reason, my advice is to speak with your physician first, and if he agrees hospice may be the best choice for you or your loved one, please remember the hospice you choose is YOUR choice.

For more than four decades, hospices in the U.S. have been trying to convince healthcare referrers (and families) to choose hospice for the exceptional care it provides during end-of-life; sadly, many physicians are still reluctant as I am sure it is difficult to have these conversations with patients you have provided care to for years. Due to unfortunate mistaken beliefs that “hospice care hastens death,” many patients are not referred to hospice when they would qualify. However, studies show that patients that receive hospice care live longer and have better quality of life than those with similar illnesses who do not receive hospice care.

Financial concerns can be a significant burden for many patients and families facing a terminal illness. Hospice care is covered under Medicare, Medicaid, and most private insurance plans, and patients receive hospice care regardless of their ability to pay. In other words, hospice offers significant savings for patients and families by providing durable medical equipment (for example, oxygen, hospital bed, walker, wheelchair, overbed table, shower chair), medical supplies (for example, wound care supplies, diapers, wipes, pull-ups), and medications specified in the patient’s Plan of Care.

Also provided under the hospice benefits are: Registered Nurses who are specially trained in pain and symptom management (available for crises 24 hours a day-7, days a week), regular visits by Hospice Aides to provide personal care, social work, and counseling services to provide emotional support for you and your family, chaplain services for you and your family, and visits by trained volunteers as needed.    

Overall, there are still many misconceptions and myths about hospice that prevent patients and families from receiving all the hospice benefits provides. Our goal in hospice is to collaborate with all healthcare professionals and continue to broaden education and understanding of how best to honor and respect patients’ wishes and concerns at the end of life.

I hold dear to my heart the words of Dr. Cicely Saunders (1967): “You matter because you are you. You matter to the last moment of your life, and we will do all we can not only to help you die peacefully, but also to live until you die”.

— Vickie C. Wacaster is a Patient and Hospice Advocate for Aveanna Hospice (formerly Comfort Care Hospice).