Nebraska Department of Insurance

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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

MARCH 2000 NICA NEWS

QUESTIONS AND ANSWERS

Q. What is hospice care and is it available to Medicare beneficiaries?

A. Hospice is a special way of caring for a patient whose disease cannot be cured and whose medical life expectancy is six months or less if the disease runs its normal course. Patients receive a full scope of palliative medical and support services for their terminal illnesses. Medicare beneficiaries certified by a physician to be terminally ill may elect to receive hospice care from a Medicare-approved hospice program. Under Medicare, hospice is primarily a comprehensive home care program that provides medical and support services for the management of a terminal illness. Beneficiaries who elect hospice care are not permitted to use standard Medicare to cover services for the treatment of conditions related to the terminal illness. Standard Medicare benefits are provided, however, for the treatment of conditions unrelated to the terminal illness. Medicare has special benefit periods for beneficiaries who enroll in a hospice program.

Q. How does Medicare determine its approved amounts for physician services?

A. Medicare's system for paying physicians is based on a national fee schedule. The schedule assigns a dollar value to each physician service based on work, medical practice costs, and malpractice insurance costs. Each of these three factors is adjusted for the geographic variation in costs. The fees that appear on the schedule are the Medicare-approved amounts for the some 7,000 physician services covered by Medicare. Each time you go to a physician for a covered service, the amount Medicare will recognize for that service will be taken from the national fee schedule. Medicare generally pays 80 percent of that amount after you have met the annual Part B deductible. You are responsible for the other 20 percent as well as all permissible charges in excess of the Medicare-approved amount.