Medicare Guidelines

Medicare is a public healthcare program managed by the Department of Health and Human Services. Generally, the program offers prescription and medical insurance along with hospital care for Americans over the age of 65.

Permanent U.S. residents and citizens will qualify for Medicare, if they’ve been working for at least 40 fiscal quarters in a position which contributed to the Medicare plan. People who are currently employed can view their paycheck stub to see if the contribution towards the plan is made.

Individuals that are diagnosed with kidney failure who needs dialysis or a transplant or for people with certain permanent disabilities can also qualify. Medicare Part A pays for inpatient stays at a skilled nursing facility or hospital. Home health care and hospice are additionally addressed within the Part A plan.

Medicare Part A requirements will be met if a person is a minimum of 65 and is getting or is eligible to get retirement benefits from Social Security or the Railroad Retirement Board. If the government employed the beneficiary or his/her spouse into a position which qualified for Medicare, they could collect additional benefits. For those under age 65, eligibility requirements of Medicare involves getting disability benefits from the Railroad Retirement Board for a minimum of two years.

Medicare Part B pertains to outpatient services that are not covered by Part A. Requirements of Part B are that a monthly premium be paid.

Medicare-Paid Hospice Admissions Must Meet Medicare Guidelines

• Medicaid and Medicare, which pay for 89% percent of United States hospice services, impose 3 strict requirements of reimbursement on an end-of-life care agency to discourage them from enrolling patients who are inappropriate.

• The attending doctor and the doctor of the hospice both must certify that the beneficiary’s illness is terminal and confirm that the patient has no more than 6 months in which to live; and offer a particular prognosis that’s accompanied by some clinical data or documentation that supports their position.

• A beneficiary or his/her representative should sign and agree to an election statement picking the Medicare hospice, and agree that they will waive curative care.

• There should be a certain hospice program of care that is periodically reviewed. It should involve the assessment of the individual’s necessities, address the management of symptom relief and discomfort, and have a statement in detail of the frequency and scope of services that are required.

• The program must be set up by an interdisciplinary group, an attending doctor, and the physician or medical director.

Hospices Violate Medicare Guidelines for Patients in Nursing Facilities

During September of 2009, the Office of Inspector General, United States Department of Human Services, let out a report of the continuous issue of widespread fraud that was committed by hospice agencies while residents in nursing homes are enrolled within hospice programs. The Office of Inspector General’s report decided the extent to which hospice claims for beneficiaries within nursing institutions within 2006 met the requirements of Medicare coverage:

• 82% of hospice claims didn’t meet a minimum of a single requirement of Medicare coverage. All non-profit hospices were a little more likely to be negligent in this regard than most for-profit agencies.

• 33% of claims didn’t meet requirements of the election statement. Commonly, the statements did not clearly explain that care in a hospice was palliative rather than curative, or that the beneficiaries had waived Medicare coverage of specific services that were related to their illnesses that were terminal.

• 63% of claims didn’t meet the requirements for plan of care, like a description in detail of the frequency and scope of services.

The Hospice Foundation of America defines that a hospice is made to provide support and comfort for those with a life-limiting illness who do not respond to treatments that are cure-oriented. But, most “life limiting” and “incurable” conditions, from heart and lung diseases, dementia, down syndrome, and spina bifida isn’t terminal. They will often respond to therapy, and sufferers could live for years.