There are several things that go on behind the scenes when you or your loved one is admitted to a hospice provider. Some of them you may never see because it doesn't impact the care provided and received. Others like the periods may only come out of the woodwork (so to write) at certain times and can either cause joy or distress depending on one's point of view.

The goal of this article is to keep it simple and smile (my version of the K.I.S.S. principal) understanding of periods. When a person is first admitted to a hospice provider (having never been on hospice), they start off (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 number 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 taken place 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 this later).

Starting with the third benefit period (first of the unlimited 60-day periods — again with fine print), a provider (doctor, PA, NP) from the hospice has to perform a face-to-face visit with the patient to also validate whether the patient is truly 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 true 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.

If the medical director determines the patient is not terminal, then the hospice benefit ends, and the patient is discharged for 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 that they may eventually get to the point where they are truly terminal.

There are events that can impact hospice benefit periods:

  1. 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 off at one benefit period higher than before such that if they were on benefit period three when they revoked, they would start off on benefit period four.
  2. Depending on how a transfer takes place from one hospice provider to another hospice provider (i.e. if the hospice provider discharges the patient vs. transferring them forcing the new hospice to do a clean admission) it is possible for the same thing to happen as revoking such that the benefit period is one higher.
  3. If a patient is admitted to the hospital and does not qualify for (see Hospice Levels of Care), 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 for benefit periods three forward, a provider must have a face-to-face with the patient prior to admission. This can create problems if the admission is urgent, and the provider is not available in a timely manner to do the face-to-face.

For those patients that 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.

Resources

Home Hospice Coverage

Hospice Levels of Care

Medicare Hospice Benefits

Medicare Hospice Benefit Facts

Medicare Benefit Policy Manual

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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