Frequently Asked Questions (FAQ) About Hospice and End of Life Planning
As complicated as hospice may sound, there are certain questions which come up repeatedly. There are many books and articles online that discuss hospice so let’s at least review some of the questions that seem to frequently come up.
Hospice care focuses on the quality of life of a person with a serious illness that is approaching the end of life. It includes emotional and spiritual support for both the patient and their loved ones. Still, deciding whether and when to start hospice can be a difficult decision, and it may cause people to feel uncertain about its appropriateness and confused or overwhelmed.
What is Hospice Care?
Hospice care is a Medicare insured service for people with serious illnesses who choose not to get (or continue) treatment to cure or control their illness. People may choose to enroll in hospice care if the treatment is unlikely to be effective or if continuing it has become too burdensome. Hospice aims to provide comfort and peace to help improve quality of life for the person nearing death. It also helps family members cope with their loved one’s illness and can also provide support to the family after the person dies, including help with grieving, sometimes called bereavement care. Medicare reimburses for hospice services when a physician determines that a patient has a life-expectancy of 6 months or less.
Many people with a serious illness use hospice care. A serious illness may be defined as a disease or condition with a high risk of death or one that negatively affects a person’s quality of life or ability to perform daily tasks. It may cause symptoms or have treatments that affect daily life and lead to caregiver stress. Examples of serious illnesses include dementia, cancer, heart failure, and chronic obstructive lung disease.
Am I eligible for hospice care?
Anyone with a serious illness who doctors think has a short time to live — generally 6 months or less —usually qualifies for hospice care. For Medicare to pay for hospice care, patients must stop medical treatment intended to cure or control their illness.
Does hospice benefit people with advanced dementia?
Most people with advanced dementia cannot communicate clearly, which means they may not be able to share their concerns with their caregivers. Caregivers may find it difficult to provide adequate care at the end of life because of this and other concerns. Hospice care can help with this situation. Hospice — whether used at home or in a medical facility — can provide caregivers and the person with dementia the support they may need near the end of life. Studies show that family members of people with dementia who received hospice report better quality of care and having more of their needs met at the end of life.
What are the benefits of using hospice care?
Studies have shown that when a person enrolls in hospice care they are more likely to have increased family satisfaction and better symptom and pain management. They are also less likely to undergo tests or be given medication they don’t need or want.
What services does hospice care provide?
Hospice care can provide a range of different services depending on your symptoms and end of life care wishes. These services include, but are not limited to, emotional and spiritual support for the person and their family, relief of symptoms and pain, help with advance care planning, therapy services, like physical or occupational therapy, and much more.
Where does hospice take place?
Hospice can be provided in many settings — a private home, nursing home, assisted living facility, or in a hospital. Many people choose to receive hospice care at home so their friends and family can visit as they wish. Other considerations may include one’s home environment vs. another setting, cost, and stability of the person’s condition. Choosing where to receive hospice care is a personal decision, but it may be helpful to talk with family members, your caregiver, or your doctor about the level of care you need and if it can be provided at home. The costs for receiving hospice care at different locations may differ. Hospice under Medicare, however, does not cover the costs of room and board at a nursing home or in your home.
Should I include hospice care in my advanced care planning?
Yes! Advance care planning involves making decisions ahead of time about the health care you would want to receive at the end of life. Studies have shown that patients who have participated in advanced care planning receive care that is more aligned with their wishes and are more satisfied with their care.
Do I have to stop all my medications if I’m on hospice?
When you begin hospice care, medication and other treatments to cure or control your serious illness will stop. For example, if you are receiving chemotherapy that is meant to treat or cure your cancer, that must end before you can enter hospice care. However, a person in hospice can continue to take medications to treat other conditions or symptoms, for example, high blood pressure.
Will my insurance cover hospice care?
Most Medicaid, Medicare, and private insurance providers will cover some of the services provided by hospice. Older adults enrolled in Medicare can receive hospice care if their healthcare provider thinks they have 6 months or less to live. In most cases, they will need to sign a statement choosing hospice care instead of other Medicare-covered treatments for their illness.
Does hospice include 24/7 care?
While some may think hospice provides 24 hours a day, 7 days a week custodial care, or full-time care at home or an) outside facility, this is rarely the case. Although hospice provides a lot of support, most of the day-to-day care of a person dying is provided by family and friends. However, a person from a hospice care team is usually always available by phone 24/7.
Is a married couple always required to spend down one half of their assets before qualifying for Medicaid?
Not always. In fact, oftentimes, couples have over $100,000 and qualify for Medicaid benefits without spending down. Although there are income and asset criteria a couple must meet before one of them qualifies for benefits, federal and state laws were written to protect individuals from becoming impoverished if their spouse needs care. Medicaid planning is like tax planning in that the laws provide certain “safe harbors” that, with expert advice from a knowledgeable professional, can save Medicaid applicants and their families thousands of dollars. An experienced elder law attorney can help you determine if there are ways to protect additional assets in your situation.
Will I lose my home?
The answer is sometimes yes and sometimes no. Many people who apply for Medicaid ask this question. For many people, the home constitutes much or most of their life savings. Often, it’s the only asset that a person must pass on to his or her children.
Under the Medicaid regulations, the home can be exempt. There are exceptions and limits of value under the new Medicaid law when calculating eligibility for Medicaid. (There may be certain issues regarding an “intent to return home” which make the home unavailable for only a certain period.)
In 1993, Congress passed a law which requires New Jersey to try to recover the value of Medicaid payments made to recipients. This process is called “estate recovery”.
Estate recovery does not take place until the recipient of the benefits dies. In the case of a married couple, it occurs after the death of both spouses under current law. At that point, the law requires New Jersey to attempt to recover the benefits paid from the recipient’s (or spouse’s) estate. In recent years, as NJ’s budget has gotten tighter, the state has become more aggressive about their estate recovery programs. For instance, New Jersey passed a law that will place a lien on a Medicaid recipient’s home under certain conditions. There also may be more frequent changes in the coming months. For that reason, you will need assistance from someone knowledgeable about the rules and regulations to determine whether there will be estate recovery, and whether it can be avoided in any situation.
Is it true that under current Medicaid laws, a parent cannot make gifts to their children once they are contemplating Medicaid or have even entered a nursing home?
No. In fact, a proper gifting program can be a great Medicaid planning technique. At the time an applicant applies for Medicaid, the state will “look back” five years to see if any gifts have been made. Any financial gifts or transfers for less than fair market value during the five year look back may cause a delay in an applicant’s eligibility. Also, just because the state may ask about gifts made during the prior five years, does not mean that all those gifts will be considered. You do need to be aware of a new law which became effective February 8th, 2006. Under the terms of that new law, the gifting rules have become far more complicated. There may be some special opportunities for asset transfers for hospice patients. My office can help determine if hospice planning could be a benefit in your situation.
I’ve heard that $13,000 is the most an individual can give away if they are going to apply for Medicaid.
No, the $13,000 figure is a gift tax figure, and not relevant to Medicaid. The maximum monetary figure Medicaid applicants need to concern themselves with is the “penalty divisor”. The penalty divisor is the state-assessed average cost for nursing home care by which the state assesses Medicaid penalties. The penalty divisor for New Jersey is currently $7,282.00. Therefore, a gift will cause a penalty of one month for each $7,282.00 given away in New Jersey.
If my house is considered “exempt” under current Medicaid laws, can I give it away without incurring penalties?
No. Any assets which are given away are considered transfers for less than fair market value. If an applicant gives the house away, NJ will assess a penalty based on the fair market value of the house at the time it was transferred.
Understanding the Difference Between Palliative Care and Hospice Care
| Question | Palliative Care | Hospice Care |
| Who can receive this care? | Anyone with a serious illness, regardless of life expectancy, can receive palliative care | Someone with a serious illness and a life expectancy measured in months, not years. |
| Can I continue to receive treatments to cure my illness? | You may receive palliative care and curative care at the same time. | Treatments and medicines aimed at relieving symptoms are provided by hospice. The goal is comfort, not cure. |
| Does Medicare pay? | Some treatments and medications may be covered by Medicare and private insurers, but not all. | Medicare pays all charges related to hospice. Most private insurers also have a hospice benefit. But again, palliative care, not hospice. |
| Does Medicaid pay? | Some treatments and medications may be covered. | In most states, Medicaid pays all charges related to hospice. |
| Does private insurance pay? | Some treatments and medications may be covered. | Most private insurers have a hospice benefit. |
| Is this a package deal? | No, there is no ” palliative care” benefit package. | Yes, hospice is a comprehensive benefit covered by Medicare and most Medicaid programs. |
| How long can I receive care? | This will depend upon your care needs, and the coverage you have through Medicare, Medicaid or private insurance. | As long as you meet Medicare’s criteria of an illness with a life expectancy of months, not years. |
| What organization provides these services? | Hospitals Hospices Nursing Facilities Healthcare Clinics |
Hospice organizations Hospice programs based out of a hospital Other healthcare organizations |
| Where are services provided? | Home Assisted living facility Nursing facility Hospital |
Usually, wherever the patient resides. In their home, assisted living facility, nursing facility, or hospital.
Some hospitals have facilities where people can live, like a hospice residence, or receive care for short-term reasons, such as acute pain or symptom management. |
| Who provides these services? | It varies. However, usually there is a team including doctors, nurses, social workers and chaplains, similar to the hospice team. | A team – doctor, nurse, social worker, chaplain, volunteer, home health aide, and others. |
Fredrick P. Niemann Esq.
If you would like to speak to our Medicaid Planning lawyers, contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com to schedule a consultation about your particular needs. He welcomes your calls and inquiries and you’ll find him very approachable and easy to talk to. Our offices are conveniently located on Route 9 North in Freehold, NJ.
Written by Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a New Jersey Hospice Care Attorney
Fredrick P. Niemann, Esq. NJ Hospice Care Attorney
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