September 21, 2020
It can be very difficult discussing care options after you or your loved one has been diagnosed with a terminal illness and has begun the end-of-life journey.
Unfortunately, many people avoid the conversation about end-of-life care not only due to the frightening topic, but also because of the fear of potentially high costs.
Thankfully, through Medicare, Medicaid, and private insurance, palliative care and hospice are made affordable. In almost all cases, there is no out-of-pocket charge to the patient or family for hospice services. Understanding what is covered and what is not covered by your insurance plan is critical when deciding to receive hospice and palliative care.
In the 1980’s, the federal government created the Medicare Hospice Benefit Program. This program was designed to provide those living with a terminal illness with the support of hospice comfort care. A majority of hospice patients have their hospice care covered by the Medicare Hospice Benefit.
In order to qualify for the Medicare Hospice Benefit, you or a loved one must meet the following requirements:
The patient must be eligible/have Medicare Part A (hospital insurance).
The patient's doctor and the hospice medical director must confirm the patient has a life-limiting illness.
Death must be expected in six months or less.
The patient must sign a statement choosing hospice care instead of routine Medicare-covered benefits for his or her illness
The patient must receive care from a Medicare-approved hospice program.
Upon qualification, and after selection of a hospice provider that is right for you, the Medicare hospice benefit covers many of the costs associated with your loved one’s end-of-life care. Examples of the costs that are covered are the following:
Doctor services & nursing care
Medical equipment & supplies related to diagnosis
Drugs for symptom control and pain relief
Short-term care in the hospital, if necessary
Physical, occupational and speech therapy
Social work services
To be certain you're not surprised with unintended bills, talk to the staff at the hospice agency. It may also be beneficial to call Medicare to confirm coverage for specific services offered to you.
While the Medicare hospice benefit program covers the vast majority of costs associated with hospice care, it is also important to know what is not covered and the potential costs that may come out of your pocket. Some of the costs that you might be responsible for are:
Prescription drug costs: The prescribed medication for pain and symptom management may require a copayment of $5 or less.
Inpatient respite care: While the majority of this cost is covered by Medicare, you may be required to pay 5% of the Medicare-approved amount. It may be a good idea to contact your hospice provider and discuss what portion of the inpatient respite costs, if any, that you may be responsible for.
Room and board charges: Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
Treatment intended to cure your terminal illness and/or related conditions
Medicaid’s coverage of hospice care services is very similar to Medicare, as both Medicaid and Medicare hospice benefits aim to make receiving hospice care extremely affordable.
Most states model their Medicaid hospice benefit coverage after the Medicare hospice benefit program. However, the Medicaid hospice benefit is optional and will vary from state to state. Contacting your state’s Medicaid agency is the best way to know what services are covered by your state’s Medicaid program.
While the majority of private insurance models their coverage after the Medicare hospice benefit program, private insurance coverage for hospice services may vary. Many employer-based and private insurance plans provide at least some coverage for hospice and palliative care.There are also different ways a person can be considered eligible for hospice care and the costs covered can vary based on the policy you hold.
To ensure you fully understand what services are covered and what costs you or your loved one may be responsible for, it is best to check with your insurance company.