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 Part A has a generous hospice benefit that covers most hospice services (PDF) 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 out-patient medications or similar products for pain relief and symptom control
- Five percent of the Medicare payment for in-patient 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 in-patient 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 (PDF). 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 (Medicaid)
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 the 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. The Veterans Administration has a description of this service on their web site, 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.
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. Be sure to check your policy carefully. Private insurers will not approve payment benefits for all agencies so you may not have a choice of which agency will provide care.
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.