Levels of Hospice Care per Medicare Law
Designed by Medicare, Hospice is supportive care to those facing life limiting illnesses. In the United States, modern hospice care is guided by the Medicare Hospice Benefit, which pays for 80% of all hospice care. Because more than 95% of hospice care is in the form of routine home care, clinicians may not be aware that the Medicare Hospice Benefit specifies four different levels of hospice services to meet the diverse needs of dying patients and their families.
For all levels of hospice, care provided is determined by the hospice plan of care, as dictated by Medicare Law. The hospice plan of care is developed by the hospice team in partnership with the patient’s attending physician. It will include, visits from the interdisciplinary team, payment for medications directly related to the patient’s terminal diagnosis, durable medical equipment and soft goods. It also includes 24 hour access to “on-call” hospice nurses.
The four (4) levels of hospice care as defined by Medicare are:
This is the most common level of hospice services in the United States. Nearly 100% of all patients are admitted at the routine level and expire at the routine level.
Core services are provided by the hospice interdisciplinary team (RN, LPN, CNA, MSW, Counselor, Volunteers) in the patient’s home. The patient’s home may be a private home, an assisted living facility, a boarding home, or a long-term care facility – wherever the patient lives.
Because hospice care is supportive care, the bulk of caregiving falls onto the patient’s family/friends – whomever is designated as the basic unit of care. Recognizing that providing care to a loved one at this stage of life can be difficult, this level of care is available to give the caregiver a rest.
Respite care is short-term (5 consecutive days) inpatient care. Often times caregivers schedule respite in order to travel, rest or to take care of their own healthcare needs. Patients may be placed in respite once every benefit period.
When a patient is in respite, it is the hospice’s financial responsibility to pay room and board to the facility where the patient is placed. The hospice agency may provide respite in a variety of contracted settings (ie. local nursing homes, assisted living facilities, etc.)
Continuous Care is intended to support the patient and their caregiver(s) through brief periods of crisis
. Care can be provided for a minimum of 8 hours and up to 24 to achieve management of acute medical symptoms. This period may last until the crisis is resolved, but the general timeframe set by Medicare is 3-5 days. The care must be predominantly skilled nursing care. Continuous home care may be provided in the home or other places of residence, such as a nursing facility.
Care must primarily be provided (more than 50%) by an LPN or RN. Home health aide and homemaker services of both may be used to the cover the additional time.
The Medicare Hospice Benefit provides for care to be provided in an acute care hospital or other setting where intensive nursing and other support is available outside of the home.
Criteria for this level of care include:
• Uncontrolled distressing physical symptoms (e.g. uncontrolled pain, intractable nausea, respiratory distress, severe wounds, etc.).
• Psychosocial problems (e.g. unsafe home environment or imminent death where family can no longer cope at home).
Inpatient hospice care can be provided in a variety of settings including dedicated inpatient hospice facilities, contracted beds within hospitals/nursing homes, or inpatient facilities. However, the key factor as stated by Medicare is…ONLY IF CARE CANNOT BE MANAGED WHERE THE PATIENT RESIDES, MAY THE PATIENT BE INPATIENT. IF THE CARE BEING PROVIDED CAN BE MANAGED IN THE HOME THEN THE PATIENT DOES NOT QUALIFY FOR INPATIENT LEVEL OF CARE.
Imminent death alone does not qualify a patient for inpatient hospice care…all hospice patients have a life limiting illness and therefore the reason why they are on a hospice program.
Under the Medicare Hospice Benefit patients may be admitted into a hospice program at any level of care as determined by their individual needs and the patient may transfer between the levels of care as needed. For patients whose hospice care is covered by a pay source other than Medicare, there may be limitations or specifications for the different levels of care.
If a patient is being cared for at a level higher than where they should be, and therefore their insurance is being billed at the higher reimbursement rate, it is considered MEDICARE FRAUD. Too often in today’s headlines this is what we read. And who suffers? Not only the patient, but those who will not receive Medicare benefits in the future for the simple fact that the funding will not be there. Think about it…it should matter to YOU!
If you suspect Medicare Fraud, it is your responsibility to confidentially report it to the Pennsylvania Department of Health’s Home Health Agency Hotline at 1-800-222-0989.
Individualized Care, Friendly Staff
Our team embraces our mission and is genuinely interested in your loved one’s well being. Call us to learn more! Catholic Hospice team members reside throughout the agency’s service area of Allegheny, Beaver, Butler and Washington counties.