Hospice
care is covered under a number of health insurance plans. It is important
to know what services are covered under each plan and what out-of-pocket
expenses you will have to pay.
MEDICARE
What is Covered, What You Pay
Medicare Part A has
a generous hospice benefit that covers most hospice services for the
terminal
illness. For example, if a patient has terminal cancer and suffers a
hip fracture, the services below are covered to provide palliative (comfort)
care for the cancer but not to treat the hip fracture. The patient would
need to use his or her Medicare
benefit to cover the care needed for the hip fracture.
The Medicare hospice benefit covers the following:
- Physician services
- Nursing care
- Medical equipment
- Medical supplies
- Medication for pain relief and symptom control
- Short-term care in a hospital
- Respite care (up to five days at a time)
- Physical, occupational and speech therapy
- Home health aide and homemaker services
- Social work services
- Dietary counseling
- Bereavement services
For the covered services listed above, the patient pays the following:
- Up to $5 for each prescription for outpatient medications or similar products for pain relief and symptom control
- Five percent of the Medicare payment for inpatient respite care
The following services are not covered under the Medicare Hospice Benefit:
- Treatment to cure the terminal illness
- Care from another provider that was not arranged by your hospice
- Care from another provider that is the same as the care available at your hospice
- Room and board, if you live in a private residence, assisted living facility, or nursing home. If, however, a patient is admitted to a hospital or nursing home under the inpatient level of care, room and board may be covered.
Note: For more information on the Medicare Hospice Benefit, the publication "Medicare Hospice Benefits" can be downloaded or you can order a copy on-line. (This document must be read using Adobe Reader; installation is available through the Adobe website.) You may also call 1-800-633-4227 to order Medicare publications.
PERIODS
OF CARE
A patient may receive hospice services for as long as the doctor certifies
that he or she is terminally ill and that, if the illness runs its normal
course, the life expectancy is less than six months. Medicare authorizes
hospice care in periods of care. A hospice patient may be certified by
the doctor for two 90-day periods, followed by an indefinite number of
60-day periods. The first period of care starts when the patient begins
to receive hospice care. At the end of each period, if the patient
is still in need of hospice care, the doctor must recertify the patient
for another period of care.
MEDICAL
ASSISTANCE
The Medical Assistance Program (also called Medicaid) pays for a
variety of services for individuals with low income. To be eligible
for any service funded by the Medical Assistance Program, an individual
must meet financial
requirements.
Forty-seven states, including Maryland, cover hospice care under their
Medical Assistance programs. In Maryland, the coverage under Medical
Assistance is virtually the same as under Medicare, except that
the hospice patient may be certified by the doctor for two 90-day
periods, followed by an indefinite number of 30-day periods.
| Medicare and Medical Assistance pay the hospice directly for services. The hospices are paid a daily rate based on the level of care the patient receives each day. |
DEPARTMENT OF VETERANS AFFAIRS
In Maryland, the Department of Veterans Affairs has inpatient hospice beds at its Perry Point Facility. Go to the Veterans Administration website for a description of this service, as well as information on VA eligibility, enrollment and benefits.
LONG-TERM CARE INSURANCE
Most long-term care insurance policies pay for hospice care. The amount of coverage and the eligibility requirements may differ. Consult your policy.
PRIVATE INSURANCE
Most private health insurance plans cover hospice. Private insurers generally use a “fee for service” model, meaning the hospice programs either bill the insurance company for each service rendered, or they bill the patient who must submit the bills to the insurance company. Coverage and payment levels differ. Many insurance plans have a lifetime ceiling for hospice benefits. Check your policy carefully! Private insurers will not approve payment benefits for all agencies; that is, you may not have a choice of agency to provide care.
UNINSURED
PATIENTS
If a patient has no
insurance coverage, or if insurance does not cover all costs, the hospice
will work with the patient and family to develop a payment plan. Most
programs have funds to provide financial assistance for low-income and
uninsured patients.