Do Medicare Advantage Plans Cover Hospice?
Explore the interplay between Medicare Advantage and hospice. Gain clarity on coverage dynamics, financial considerations, and plan implications.
Medicare Advantage plans, also known as Medicare Part C, are health insurance options offered by private companies that contract with Medicare. These plans provide an alternative way to receive Medicare benefits, often bundling hospital insurance (Part A), medical insurance (Part B), and typically prescription drug coverage (Part D) into a single plan. Hospice care is a specialized form of medical care focusing on comfort and quality of life for individuals with a life-limiting illness, typically when a cure is no longer possible. This type of care emphasizes pain and symptom management, along with emotional and spiritual support for both the patient and their family.
Hospice Coverage Under Medicare Advantage
When a Medicare beneficiary elects hospice care, Original Medicare, specifically Medicare Part A, becomes the primary payer for all services related to the terminal illness, even if the individual is enrolled in a Medicare Advantage plan. This arrangement is a specific rule within the Medicare program, often referred to as the “hospice carve-out.” This transition ensures that beneficiaries receive comprehensive hospice services under a standardized benefit, regardless of their private plan enrollment.
The Medicare Advantage plan’s role for hospice-related services is to help the beneficiary locate a Medicare-approved hospice provider. While Original Medicare takes over for hospice-related care, the Medicare Advantage plan may continue to cover medical services not related to the terminal illness.
Understanding Hospice Eligibility and Covered Services
To qualify for hospice care under Medicare, an individual must meet specific criteria. A physician, along with the hospice medical director, must certify that the patient has a life expectancy of six months or less if the illness runs its normal course. The patient or their authorized representative must also choose comfort care (palliative care) over curative treatments for the terminal illness. This election of hospice care requires signing a statement acknowledging the choice.
Once eligible, the Medicare hospice benefit covers a comprehensive range of services designed to provide comfort and manage symptoms, including:
Physician and nursing care
Medical equipment such as wheelchairs and hospital beds, and necessary medical supplies like bandages
Drugs for pain and symptom management
Hospice aide and homemaker services
Physical and occupational therapy
Speech-language pathology services
Social worker services
Dietary counseling
Grief and loss counseling for the patient and family
Short-term inpatient care for pain or symptom management
Respite care to give caregivers a break
Costs for Hospice Care
Medicare’s coverage for hospice care is extensive, resulting in minimal out-of-pocket costs for beneficiaries. Medicare covers 100% of the costs for hospice care, provided the care is received from a Medicare-approved hospice provider.
Beneficiaries may encounter a small copayment for prescription drugs used for pain and symptom management, typically up to $5 per prescription. A 5% coinsurance may apply for inpatient respite care, which is short-term care in a facility to offer a caregiver a break.
Impact on Medicare Advantage Enrollment
A beneficiary electing hospice care retains their Medicare Advantage plan enrollment, even though Original Medicare becomes responsible for hospice services. The Medicare Advantage plan continues to cover all medical services that are not related to the terminal illness for which hospice care was elected. For example, if a hospice patient breaks an arm, their Medicare Advantage plan would cover the treatment for the broken arm under its usual terms.
Beneficiaries continue to pay their Medicare Advantage plan premium, if any, during this time. This dual coverage arrangement, where Original Medicare covers hospice care and the Medicare Advantage plan covers unrelated medical needs, is a specific design feature of the Medicare program. While beneficiaries have the option to disenroll from their Medicare Advantage plan and return to Original Medicare at any time, it is not a requirement for electing hospice care.