Who Pays for Inpatient Hospice Care?

Inpatient hospice care provides short-term, intensive support in a specialized facility, focusing on comfort and quality of life for individuals facing a terminal illness. This care shifts the emphasis from curative treatments to managing pain and other symptoms, aiming to ensure peace and dignity in life’s final stages.

Medicare Coverage for Inpatient Hospice Care

Medicare is a primary payer for hospice care in the United States, offering a comprehensive benefit for eligible individuals. To qualify for the Medicare Hospice Benefit, an individual must have Medicare Part A and be certified by both their attending physician and a hospice physician as terminally ill, with a prognosis of six months or less to live if the illness runs its normal course. Upon electing the hospice benefit, the focus shifts to palliative care for pain relief and symptom management, rather than curative treatment.

The Medicare Hospice Benefit covers a wide range of services related to the terminal illness, with most costs covered. Covered services include:
Physician services
Nursing care
Medical equipment and medications for pain and symptom management
Medical supplies
Physical and occupational therapy
Speech-language pathology services
Dietary counseling
Social work services
Spiritual counseling
Hospice aide and homemaker services
Short-term inpatient care, including respite care

Short-term inpatient care is provided when symptoms cannot be managed in other settings. Respite care offers temporary relief for caregivers, typically for up to five consecutive days. While Medicare pays almost all costs related to hospice care, beneficiaries may have a small copayment for prescription drugs and a small coinsurance (5%) for inpatient respite care. The hospice provider must be Medicare-certified for services to be covered.

Medicaid and State Assistance Programs

Medicaid covers inpatient hospice care for individuals with limited income and resources. As a joint federal and state program, Medicaid’s eligibility criteria and specific benefits vary by state, though all states are required to cover hospice services. Eligibility is generally based on state-established income and asset limits.

Medicaid can act as a primary payer for those who do not qualify for Medicare, or as a secondary payer. In some instances, it may cover services not fully paid by Medicare, such as certain room and board costs in a nursing home if hospice care is provided there. The services covered by Medicaid for inpatient hospice care largely mirror Medicare’s comprehensive benefit.

Similar to Medicare, individuals must be certified as terminally ill by a physician, typically with a prognosis of six months or less, and elect to receive hospice care. The Medicaid hospice benefit also includes short-term inpatient care as well as respite care. Hospice services under Medicaid are typically covered at 100% with no out-of-pocket costs for patients.

Private Health Insurance Coverage

Private health insurance coverage for inpatient hospice care varies by policy and plan type. Many private plans model their hospice coverage after the federal Medicare benefit program. Individuals should contact their insurance provider to understand their plan’s specific details.

Investigate whether hospice care is a covered benefit, and what deductibles, co-payments, or coinsurance amounts apply. Plans may also have annual out-of-pocket maximums that limit the total amount a patient would pay in a year. Using in-network hospice providers can maximize benefits and reduce out-of-pocket expenses.

Some private insurance plans may require pre-authorization before inpatient hospice care begins. There might also be limitations on the duration or type of hospice services covered under the policy. Most private plans require a patient to be diagnosed with a terminal illness, typically with a life expectancy of six months or less, and to discontinue curative measures.

Other Funding Sources

Beyond Medicare, Medicaid, and private insurance, other avenues can help cover inpatient hospice care costs. Eligible veterans can receive comprehensive hospice care through the Department of Veterans Affairs (VA). To qualify, veterans must be enrolled in VA healthcare benefits, be diagnosed with a life-limiting illness with a prognosis of six months or less, and elect to receive hospice care in lieu of curative treatment.

The VA covers a comprehensive range of hospice services, often with no co-pays or out-of-pocket costs for eligible veterans. This coverage extends whether the care is provided directly by the VA or by an organization operating under a VA contract.

In situations where individuals do not qualify for other benefits or their insurance coverage is insufficient, out-of-pocket payments may be necessary. Hospice providers often employ financial counselors who can discuss payment plans and options. Additionally, many non-profit hospice organizations offer financial assistance or charitable care programs based on a patient’s demonstrated need. These programs can provide support for patients who cannot afford the full cost of care, helping to ease the financial burden on families.