Several things go on behind the scenes when you or your loved one is admitted to a hospice provider. You may never see some of them because they don’t impact the care provided and received. Others, like the hospice benefit periods, may only come out of the woodwork (so to write) at certain times and can cause joy or distress depending on one’s point of view.
This article aims to keep it simple and smile (my version of the K.I.S.S. principal) understanding of hospice benefit periods. When a person is first admitted to a hospice provider (having never been on hospice), they start (behind the scenes) in benefit period number one. This is the first half (90 days/3 months) of the estimated six months or less to live. Benefit period two is the second half (3 more months/90 days). And since a terminal illness doesn’t come with guarantees that one will pass in six months or less, Medicare allows for (with fine print through the entire journey) an unlimited number of sixty-day (two months at a time) benefit periods.
Approximately two weeks before the end of each benefit period, a registered nurse case manager must evaluate the patient for “recertification,” which documents the specific types of downward changes that have occurred since admission and the previous (if applicable) recertification. The recertification visits must be discussed during the hospice providers’ interdisciplinary team (IDT/IDG) meeting with their medical director, who can approve or disapprove the recertification (more on later).
Starting with the third benefit period (the first of the unlimited 60-day periods—again, with fine print), a provider (doctor, PA, NP) from the hospice has to visit the patient face-to-face to validate whether the patient is indeed terminal.
Now to the fine print. Medicare requires the patient to be terminal to be on hospice. The understanding of “terminal” is approximately six months or less; again, with the understanding that since only God is God, and there are no accurate tests for the exact length of time someone has when they have a progressive, incurable disease… there’s a need to check often over time if the patient is truly terminal. The recertification visits, along with any face-to-face visits, are those checks and balances.
Suppose the medical director determines the patient is not terminal. In that case, the hospice benefit ends, and the patient is discharged for an extended prognosis (sometimes referred to as failure to decline). The hard part for some families where the patient is extremely sick but not terminal is they take the news as “my ______ (dad, mom, uncle, aunt, etc.) isn’t dying fast enough.” That’s not the case; the case is they are not terminal, which means they may recover or eventually get to the point where they are genuinely terminal.
Some events can impact hospice benefit periods:
If a patient revokes hospice (it is an elective service; the patient and family can stop hospice at any point, even if the patient is terminal) and then comes back onto hospice, they start at one benefit period higher than before. Thus, if they were on benefit period three when revoked, they would start on benefit period four.
Depending on how a transfer takes place from one hospice provider to another (e.g., if the hospice provider discharges the patient instead of transferring them and forcing the new hospice to make a clean admission), it is possible for the same thing to happen as revoking, such that the benefit period is one higher.
Suppose a patient is admitted to the hospital and does not qualify for GIP (see Hospice Levels of Care). In that case, the patient has to revoke hospice (to avoid insurance problems) and then get re-admitted, which pushes the patient into the next benefit period.
The above matters for re-admission to hospice because a provider must meet with the patient face-to-face before admission from benefit periods three forward. This can create problems if the admission is urgent and the provider is not available promptly to do the face-to-face.
For those patients who remain in hospice for their terminal illness without dealing with revocation or concern about a slow decline (that may indicate they are not terminal), hospice benefit periods rarely come up in discussion.
