Yes. Medicare can cover both home health and hospice care when a patient meets the requirements for each benefit.
The confusing part is that the two benefits are designed for very different needs.
Home health is generally used when someone needs skilled care at home because of an illness, injury, surgery or change in condition. Hospice is designed for someone with a terminal illness whose care has shifted toward comfort rather than treatment intended to cure that illness.
Understanding how Medicare approaches each can make the process a lot less intimidating.
Medicare Part A and Part B can cover eligible home health services provided by a Medicare-certified home health agency.
To qualify, a patient generally must:
Being homebound does not mean someone can never leave the house. It generally means leaving home is difficult because of an illness or injury and requires considerable effort or assistance.
When eligibility requirements are met, Medicare-covered home health may include services such as:
The care has to be medically necessary and part of the patient’s plan of care.
Under Original Medicare, patients generally pay $0 for covered home health services.
Durable medical equipment works differently. After the Part B deductible is met, the patient generally pays 20% of the Medicare-approved amount for covered equipment.
Medicare does not use the home health benefit to pay for things like:
That last point is important because “home health” and “home care” are often used interchangeably in everyday conversation even though Medicare treats them very differently.
Medicare Part A covers hospice care for eligible patients.
A patient generally qualifies for the Medicare hospice benefit when:
The six-month prognosis does not mean hospice automatically stops after six months.
Medicare allows hospice care to continue as long as the patient remains eligible and is appropriately recertified. The benefit begins with two 90-day periods and can continue through an unlimited number of 60-day benefit periods.
The Medicare hospice benefit is designed around comfort and management of the terminal illness and related conditions.
Depending on the patient’s plan of care, hospice may include:
The hospice team coordinates the care related to the terminal illness.
For Medicare-approved hospice care, patients generally pay nothing for the hospice services themselves.
There can be some limited out-of-pocket costs.
Medicare may require a copayment of up to $5 for certain outpatient prescription drugs used for pain and symptom management, and patients may pay 5% of the Medicare-approved amount for short-term inpatient respite care.
Medicare also generally does not pay room and board simply because someone is receiving hospice in a nursing facility or other residential setting. Short-term inpatient or respite care arranged by the hospice is treated differently.
Choosing hospice does not mean Medicare disappears.
Original Medicare can still cover treatment for health conditions that are unrelated to the terminal illness and related conditions, subject to the normal deductibles and coinsurance that apply.
For care connected to the terminal diagnosis, however, the hospice team becomes responsible for coordinating the services covered under the hospice benefit.
That is one reason families should contact the hospice team before seeking emergency, hospital or other treatment related to the terminal illness. Care that is not arranged appropriately may not be covered under the hospice benefit.
Patients enrolled in a Medicare Advantage plan should check their plan for details about home health coverage, since plan requirements and networks may differ. Medicare specifically advises Medicare Advantage members to contact their plan for information about their home health benefits.
Hospice works somewhat differently. Medicare Part A hospice benefits continue to apply when an eligible patient elects hospice, while the patient’s other coverage may still apply to services unrelated to the terminal illness.
Because insurance situations can vary, it is worth confirming the details before care begins.
This may be the most important part.
Families sometimes delay calling because they are trying to determine eligibility, coverage and costs on their own first.
You do not need to have all of that figured out.
If someone may need skilled care at home, or if a serious illness has progressed and the family is beginning to consider hospice, the first step can simply be a conversation.
The Benchmark team can help explain the care options, work with the patient’s healthcare providers and help determine what the next steps may look like.
The care you deserve.
Call Benchmark at 936-274-3787. Our team can help you understand what questions to ask and where to start.
Whether you're exploring care options for a loved one or need assistance with any questions, we're here to help.
