Medicare offers a hospice benefit to plan holders with a terminal illness. This benefit allows an individual to receive palliative, quality end-of-life care.
In this article, we cover the many aspects of hospice care under Medicare, including cost considerations and where a person can receive care.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers a variety of services, equipment, and medications under an individual’s hospice care benefit, including:
- dietary counseling
- doctor’s services
- grief and loss counseling for the insured person and their family
- medical equipment and supplies
- nursing care
- physical therapy
- prescription medications
- respite care to provide a person’s caregiver with rest for up to 5 days at a time
- medically necessary, short-term inpatient care for pain or symptom management
Hospice coverage can vary according to a person’s unique situation. The key aspect of coverage is that hospice care represents a shift from curative to comfort oriented treatments.
Once a person triggers their hospice benefit, Medicare may not pay for doctor’s visits or medications that aim to treat the condition.
Any person who is eligible for Medicare Part A can qualify for hospice benefits.
To receive Medicare Part A hospice care benefits, a person must meet the following criteria:
- A regular doctor and hospice doctor must certify that a person is terminally ill and is likely to live for less than 6 months.
- A person must accept palliative care to provide comfort instead of care that aims to cure or treat their illness.
- The insured person signs a statement indicating their desire to receive hospice care instead of other Medicare covered treatments for their condition.
Through Medicare, a person has a legal entitlement to a one-time hospice consultation with a hospice doctor or director to discuss hospice care. They do not need to choose hospice care, even if they agree to it at this meeting.
What happens if a person lives longer than 6 months?
If this is the case, a hospice provider can recertify that a person is terminally ill. Ideally, hospice benefits will continue.
According to a 2016 study, the average Medicare hospice stay is 86 days.
A person also has the right to stop hospice care at any time if they wish to do so.
Medicare will pay a person’s hospice provider directly for their services. When a person enters a hospice program, they do not have to meet a deductible for hospice care.
However, some associated costs apply. These include:
- continuing to pay monthly premiums for Medicare Parts A (if applicable) and B
- paying a copayment of up to $5 for prescription pain medications or other medications to manage discomfort
- paying a 5% coinsurance of the Medicare approved amount for inpatient respite care
If a person’s condition means that they need hospital treatment while in hospice care, a hospice organization must make the arrangements. This is vital, as the hospice provider will pay the hospital directly.
If a person has a Medicare Supplement Insurance policy, also known as Medigap, this may help to cover out-of-pocket expenses.
For specific questions about Medigap coverage, a person should contact their plan administrator.
Hospice care provides support and care for those who are approaching the end of their lives, as well as their families.
A hospice program changes the focus of treatment. The focus shifts from actively resolving medical conditions to providing comfort and supportive care to allow a person to live out their life, on their terms, as much as possible.
Usually, people do not receive hospice care until their medical condition is near the last 6 months of their lives.
A person in hospice care usually receives care in their own home, but the location may vary. Examples of services a person may receive in hospice care include:
- counseling about end-of-life concerns
- medical equipment to support comfort and mobility, such as hospital beds, walkers, or other assistive devices
- medications that ensure a person is as comfortable as possible, such as painkilling medications
- physical care, such as help with bathing, feeding, and getting dressed
- other supplies or services that may make a person more comfortable
People with many chronic medical conditions, such as cancer, COPD, congestive heart failure, dementia, may benefit from hospice services.
When lawmakers first added the hospice care benefit to Original Medicare, they limited hospice care to a person’s home.
In 1989, Medicare extended eligibility for hospice care to those living in nursing facilities.
If a person lives in a nursing facility, such as a nursing home or assisted living facility, they receive the same hospice care benefits as a person who lives in their own home.
Sometimes, a person may also start hospice care in their home, yet their care needs change so that they require a transfer to a nursing home. Medicare will also provide hospice coverage in this circumstance.
However, Medicare does not cover room and board when a person receives hospice care in their home or another facility, such as a nursing home.
Therefore, if a person requires transfer to a nursing home, they are responsible for the room and board costs. However, Medicare will continue to fund their hospice services.
The same is true if a person lives in an apartment or other living situation where they pay rent.
When a person enters hospice care, the hospice provider becomes responsible for funding their services.
If a person requires care that does not relate to their terminal illness, Medicare or Medicare Advantage still covers these costs.
If a person requires further care due to their terminal illness, they must arrange this care with their hospice. This might include doctor’s visits or emergency room care.
To enter hospice care, a person agrees to stop treatments that aim to cure their condition.
A hospice organization should carefully go over these treatments with the individual. This will help them fully understand what treatments will and will not form part of their hospice care.
Securing hospice care through Medicare depends upon the type of plan. Both programs require that a person chooses a Medicare approved hospice.
An estimated 4,382 hospices operating in the United States in 2016 had Medicare approval.
To find Medicare approved hospices for Original Medicare, a person may call Medicare (1-800-633-4227) and ask for the phone number for their state’s hospice organization.
A person can also search for hospice providers by visiting Medicare.gov.
However, people with Medicare Advantage programs, such as PPOs or HMOs, may need to select a specific hospice provider within their plan’s network.
A person can contact their plan administrators to ask for a list of approved local providers.
While Medicare Part A provides coverage for a person in hospice care, they can still keep their Medicare Advantage policy, so long as they pay their premiums.
Hospice care can significantly reduce hospital stays and trips to the emergency room that a person may otherwise experience as they approach the end of their life.
Medicare pays for this benefit to provide as much comfort and peace as possible for people with terminal illnesses in their last days.
Once coverage for hospice care begins, coverage for standard treatment no longer applies.
If a person with Medicare is in the final stages of their terminal illness, their doctor may discuss the possibility of hospice care as a way to ensure their comfort.