Two reasons can stop you from making plans for hospice care. First, you may want to avoid thinking about the care you’ll need at the end of your life. But, according to the Centers for Disease Control (CDC), the number of patients in hospice in 2013 totaled 1.3 million. Being unprepared isn’t the best strategy.
The second reason you might put off planning is that you think that Medicare will pay for hospice care. While Medicare does cover many hospice expenses, it doesn’t cover all of them. Besides, 17 percent of people that need hospice care are under the age of 65 and don’t have Medicare coverage.
Here’s the information you need to determine how to prepare in case you or a loved one needs hospice care.
Hospice care is a specialized type of care for people facing an illness that will limit their lifespan. It also supports the person’s families and caregivers.
In general, a person is eligible for hospice services if their doctor certifies that the person is terminally ill, and has a life expectancy of 6 months or less.
When someone starts hospice care medical personnel, social workers, and spiritual leaders work together to provide comfort and pain management. There is no treatment provided to cure the person’s illness. Medical personnel have already exhausted all alternatives for a cure. The focus moves to offering symptom relief.
Prescription drugs for pain relief or symptom control
Social worker services
Hospice aid and/or homemaker services
Physical and occupational therapies
Medical appliances, and supplies such as drugs to relieve pain
Short-term inpatient care
Short-term respite care
Bereavement services for families
Hospice providers offer care to the patient wherever they live. For example, a hospice patient can receive care at home, in a nursing home, assisted living home, or any long-term care facility. Hospice providers may offer care for an inpatient in a hospital, but insurance may not cover those services.
When you and your physician decide that you or a loved one needs hospice services, you can contact a hospice organization to obtain those services. Most of the time, your physician can refer you to a hospice provider in your area. Once a patient enters a hospice program, that provider manages the plan for continuing care.
Medicare, most states’ Medicaid, The Veteran’s Health Administration, and private insurance companies provide coverage for hospice care. Medicare sets the standard for covering hospice care and most other insurance companies design their coverage to correspond to the Medicare coverage described below. However, it’s important to check with non-Medicare insurance companies to verify whether there are variations in their coverage.
Medicare Part A covers hospital insurance, and if you meet the criteria for hospice, Part A will cover your hospice costs. The requirements are:
Your doctor has certified that you’re terminally ill with a life expectancy of 6 months or less
You accept care to manage your illness’ symptoms instead of care to cure the terminal illness
You sign a statement choosing hospice care rather than other care covered by Medicare
You must work with a hospice provider that the state or federal government has certified and licensed. You can stay on hospice care after the 6-month period if the hospice team certifies that you are still terminally ill. If your health improves, you can stop the hospice program. Your hospice care can run for two 90-day periods, followed by an unlimited number of 60-day periods. At the end of each period, the hospice team must rectify that you are terminally ill.
Medicare covers the majority of hospice care, meaning the care you receive from a hospice provider as described above. However, there are things that Medicare doesn’t cover.
For example, you may need to pay a $5 copay for prescription drugs, or a 5 percent coinsurance for inpatient respite care. It’s important to talk to your health care provider about costs for specific tests, prescriptions or other items the hospice care team recommends. How much you will need to pay depends on:
Whether you have extra insurance, such as a Medigap or Advantage Plan, or a Part D Drug Plan How much the doctor charges
Whether the doctor accepts assignment (the amount Medicare pays for services)
The type of facility you’re in
Where a test or service is performed
Medicare does cover a wide range of the costs of hospice care, but there are notable exceptions:
Treatment or prescription drugs to cure your terminal illness or other conditions. You can always stop hospice care at any time. But, once you have accepted hospice care, treatments intended to cure aren’t covered.
Care that your hospice provider didn’t order. Once you choose a hospice provider, any care you receive must come from that provider. You can’t use two hospice providers at the same time, although you can change which hospice provider you want to work with. You can see your personal physician or nurse if you’ve identified them as the attending medical professional who will oversee your care.
Room and board. Hospice care providers will deliver care in a variety of places, but the cost for the patient to live in any of those isn’t covered. So, if you can’t be cared for at home, you’ll need to pay for staying in a long-term care facility. Medicare will cover an inpatient stay in a facility for short-term inpatient care. Medicare will also cover short-term inpatient respite care, but you will be responsible for the 5 percent coinsurance.
Some hospital care or ambulance transportation. Medicare won’t pay if you need inpatient hospital care, outpatient care such as a trip to the emergency room, or travel via an ambulance. The only exception is if your hospice team ordered those activities, or they are unrelated to your terminal illness.
If you elected to buy a Medicare Advantage Plan, Medicare Part A would still provide the hospice benefit. You can get covered services using your Advantage plan for any health issues that are unrelated to your terminal illness. If your Advantage plan covers other services such as dental and vision, those services will be covered while you’re in hospice. You’ll need to check with your Advantage plan provider to determine whether they cover hospice co-pays and coinsurance.
If you have elected to buy a Medigap plan, most of them will pay for hospice co-pays and coinsurance. Check with your Medigap provider to verify the details.
The time to plan for hospice care is before you need it. How will you pay for the hospice costs that Medicare and similar providers don’t cover? You can buy a Medigap or Medicare Advantage policy that may cover co-pays and coinsurance.
You could also invest in long-term care insurance or life insurance to cover the costs of getting the care you need if staying at home isn’t an option. If you need the services of a long-term care facility, the costs can be staggering. For example, as of 2016, a semi-private room in a nursing home cost $6,844 per month, and the cost in an assisted living facility can run $3,628 per month.
Planning now will significantly reduce the burden on you and your loved ones in the future.