Does Insurance Cover Hospice? A Breakdown of Coverage

Hospice care offers support and comfort for individuals facing life-limiting illnesses. This specialized care focuses on managing pain and other symptoms to improve the patient’s and family’s quality of life. Understanding how various insurance programs cover these services is important for individuals navigating this challenging time. This article outlines the coverage provided by different insurance types, clarifying what to expect when considering hospice care.

Medicare Hospice Benefits

Medicare Part A offers a comprehensive hospice benefit for eligible individuals. To qualify, a physician must certify that the patient has a terminal illness with a prognosis of six months or less. This certification must come from both the patient’s attending physician and a hospice physician. Patients must also elect to receive palliative care, focusing on comfort, rather than curative treatments for their terminal illness.

The Medicare hospice benefit includes a wide range of services. These typically encompass physician and nursing services, medical equipment, and necessary medical supplies. Medications for pain relief and symptom control are also covered. Furthermore, the benefit extends to medical social services, spiritual and bereavement counseling for the patient and family, and various therapies like physical, occupational, and speech-language pathology services. Hospice aide and homemaker services are also part of this comprehensive coverage.

Medicare hospice benefits are structured into benefit periods: two 90-day periods followed by an unlimited number of 60-day periods. At the beginning of each subsequent benefit period, a hospice medical director or physician must recertify the patient’s terminal illness through a face-to-face encounter. While most hospice care is fully covered, some minor costs may apply; for instance, a copayment of up to $5 for each outpatient prescription drug, and a 5% coinsurance for inpatient respite care.

Medicare generally does not cover certain items once the hospice benefit begins. This includes treatments intended to cure the terminal illness, prescription drugs not used for symptom control or pain relief, and care from providers not arranged by the hospice team. Additionally, Medicare typically does not cover room and board costs if the patient receives hospice care at home, in a nursing home, or in an inpatient hospice facility, unless it is for short-term inpatient or respite care arranged by the hospice team.

Medicaid Hospice Benefits

Medicaid also provides hospice coverage. While hospice is an optional service for states to offer, all states currently include it in their Medicaid programs. The eligibility for Medicaid hospice benefits is primarily based on income and asset limits, which vary by state. Services covered under Medicaid hospice benefits are often similar to those provided by Medicare, focusing on palliative care rather than curative treatment.

When an individual elects the Medicaid hospice benefit, they generally waive their right to other Medicaid services for the cure or treatment of their terminal condition. However, individuals under age 21 are an exception and can receive both curative care and hospice care concurrently. Patients can revoke their hospice election at any time and resume other Medicaid-covered benefits.

Medicaid hospice care is typically provided by a team of professionals who create an individualized plan of care. This plan addresses the patient’s physical, psychological, emotional, and spiritual needs. Services usually include nursing care, physician services, medical social services, counseling, medical equipment, supplies, and medications. Short-term inpatient care and respite care are also commonly included.

Private Health Insurance Hospice Benefits

Coverage for hospice care through private health insurance plans varies considerably. Benefits depend on the specific policy terms. Many private plans, however, model their hospice benefits after the Medicare hospice benefit.

Individuals with private insurance should review their policy’s Summary of Benefits and Coverage (SBC) or contact their insurance provider directly to understand their specific hospice coverage. This clarifies potential deductibles, co-pays, and co-insurance amounts that may apply. Some plans may also have network restrictions, requiring care from specific hospice providers, or prior authorization requirements for certain services.

While many private insurance plans cover a significant portion of hospice costs, the variability necessitates proactive inquiry. Understanding these policy details informs patients and their families about any out-of-pocket expenses or specific steps required to access benefits. This includes knowing whether the plan requires a physician’s certification of a terminal illness with a limited prognosis, similar to Medicare guidelines.

Other Hospice Coverage Programs

Beyond Medicare, Medicaid, and private insurance, other programs offer hospice coverage. TRICARE, the healthcare program for active duty and retired military personnel and their families, covers Medicare-approved hospice. TRICARE’s hospice benefit includes services similar to Medicare, such as physician services, nursing care, medical equipment, and medications. It covers four levels of care, including routine home care, continuous home care, inpatient respite care, and general inpatient care, though it typically does not cover room and board unless for inpatient or respite care.

The VA also provides comprehensive hospice benefits for eligible veterans. To qualify, a veteran must be enrolled in VA healthcare, have a terminal illness with a prognosis of six months or less, and elect to receive hospice care in lieu of curative treatment. VA hospice care covers pain and symptom management, emotional counseling, spiritual support, and social work services, often with no copays. This benefit allows veterans to receive care at home, in a nursing home, or in a dedicated VA hospice unit.