What Type of Plan Normally Includes Hospice Benefits?

Hospice care offers support for individuals facing a life-limiting illness. This specialized approach focuses on managing symptoms and enhancing quality of life rather than pursuing curative treatments. Understanding which types of plans typically provide coverage for these services can help individuals and their families navigate this period.

Understanding Hospice Care

Hospice care is a philosophy focused on providing comfort and support for individuals with a terminal illness, prioritizing quality of life over curative measures. It involves a holistic approach, addressing physical, emotional, social, and spiritual needs. An interdisciplinary team, including doctors, nurses, social workers, spiritual counselors, and trained volunteers, works together to provide comprehensive care.

Eligibility for hospice requires a medical prognosis of six months or less. Care can be provided in various settings, such as a patient’s home, a dedicated hospice inpatient facility, a nursing home, or a hospital. Hospice care is delivered through four recognized levels:
Routine home care
Continuous home care during times of crisis
General inpatient care for symptom management
Inpatient respite care to offer temporary relief to caregivers

Medicare Hospice Benefits

Medicare Part A provides comprehensive hospice benefits for eligible individuals. To qualify, a person must be entitled to Medicare Part A and have two physicians certify a life expectancy of six months or less. The individual must also choose comfort care for their terminal illness instead of curative treatments.

Medicare’s hospice benefit covers a range of services, including:
Physician services
Skilled nursing care
Medical equipment (e.g., wheelchairs, hospital beds) and supplies (e.g., bandages, catheters)
Drugs for pain and symptom management related to the terminal illness
Physical, occupational, and speech-language pathology services
Hospice aide, homemaker, and social worker assistance
Dietary counseling
Grief or bereavement counseling for the patient and their family
Short-term inpatient care for acute symptom management
Short-term respite care to support caregivers

Medicare’s hospice benefit does not cover curative treatments or prescription drugs not used for symptom control. Care from providers not arranged by the hospice team is also not covered. Medicare does not pay for room and board in a nursing home or other long-term care facility, unless it is for short-term inpatient or respite care arranged by the hospice team. There are no deductibles for hospice care, but a small copayment may apply for prescription drugs and respite care.

Medicaid and Private Health Insurance Hospice Coverage

Medicaid programs in all states provide coverage for hospice services, often aligning their benefits with the Medicare model. Eligibility for Medicaid hospice depends on meeting state-specific income and asset requirements, in addition to terminal illness criteria. Some state Medicaid programs may also cover room and board costs for eligible individuals receiving hospice care in a long-term care facility, a benefit not covered by Medicare.

Private health insurance plans offer hospice coverage, though specifics vary significantly among plans and insurers. Many private plans base their hospice benefits on the Medicare model, including similar eligibility criteria and covered services. These plans may have different network requirements, deductibles, co-pays, or prior authorization rules. Individuals with private insurance, including employer-sponsored plans or those purchased through the Affordable Care Act Marketplace, should contact their provider or review policy documents to understand their hospice benefits and potential out-of-pocket costs.

Initiating Hospice Benefits

The process of initiating hospice benefits begins with a medical professional’s referral. A patient’s attending physician, along with a hospice physician, must certify the terminal illness and prognosis to establish eligibility. Patients or their legal representatives can also self-refer by contacting a hospice provider to discuss their needs.

After eligibility is confirmed, the patient or their representative signs an election statement. This document indicates the patient’s choice to receive hospice care, signifying a focus on comfort rather than curative treatment. This election does not prevent individuals from receiving medical care for unrelated conditions. The hospice team then conducts an initial comprehensive assessment to develop a personalized care plan addressing the patient’s and family’s needs. Patients retain the right to revoke their hospice benefit at any time to pursue curative treatment, and they can re-elect hospice care later if they meet eligibility requirements.