Medicare Advantage And Hospice
If you are enrolled in a Medicare Advantage plan, such as an HMO or PPO, and you need to access hospice care services, begin by consulting your specific plan in order to find an approved provider near you. Your plan must help you find Medicare-approved hospice care providers in your area.
In order to qualify for end-of-life care, also known as hospice care, on Medicare Advantage, your primary care doctor and your hospice doctor must certify that you are terminally ill and only have six months or less to live. Patients that live longer than six months may qualify forspice care.
This is how it works. You will initially receive hospice care in two 90-day benefit periods. These periods can be followed by an unlimited number of 60-day periods, as long as the hospice medical director or other hospice doctor certifies that you are still terminally ill at the beginning of each period. Additionally, youâll have the option to switch hospice providers once during each benefit period.
Once you begin receiving hospice care, the services are provided through Original Medicare , though you can still maintain your Medicare Advantage plan to cover conditions unrelated to your terminal illness. The hospice benefit is designed to cover all needs related to your terminal illness and associated conditions.
In addition to you and your family, members of your hospice care team may include:
- Hospice doctors
If You Have Medicare Advantage
If you need hospice and have a Medicare Advantage Plan, your plan can help you find a hospice provider that is Medicare-certified. The hospice benefit is covered under Original Medicare. Medicare Advantage doesnt cover hospice, so its provided through Original Medicare during the hospice period.
If you choose hospice care, your Medicare Advantage plan will continue to cover health care services unrelated to the terminal illness. You can also choose providers not in the plans network who will bill Original Medicare, and you will be responsible for cost-sharing under Original Medicare.3
If you leave hospice care, your Medicare Advantage Plan will revert to your primary coverage beginning on the first of the following month.4
How Medicare Covers Hospice Care
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When someone is diagnosed with a terminal illness and has less than 6 months to live, hospice care is often the treatment of choice. But like any medical treatment, its expensive. Does Medicare cover hospice care and if it does, how much?
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Will Hospice Shut Off My Other Healthcare Services
Technically speaking, patients on hospice should still beable to receive healthcare not related to the hospice diagnosis. Since thehospice benefit gives the hospice agency a bundled payment for all the carerelated to the hospice diagnosis, Medicare will not pay for related serviceselsewhere. They would consider that paying twice for the same diagnosis.However, not all healthcare would be related to the hospice diagnosis. Forinstance, if a man receiving hospice for COPD is bitten by his cat, he couldstill go to his normal doctor to have the cat bite treated.
How Long You Can Get Hospice Care
Hospice care is for people with a life expectancy of 6 months or less . If you live longer than 6 months, you can still get hospice care, as long as the hospice medical director or other hospice doctor recertifies that youre terminally ill.
- You can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods.
- You have the right to change your hospice provider once during each benefit period.
- At the start of the first 90-day benefit period, your hospice doctor and your regular doctor must certify that youre terminally ill . At the start of each benefit period after the first 90-day period, the hospice medical director or other hospice doctor must recertify that youre terminally ill, so you can continue to get hospice care.
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Choosing Between Original Medicare And Medicare Advantage
Seniors receiving a hospice care benefit can choose to leave their Medicare Advantage plan once hospice care begins, but they must pay Original Medicare premiums.
Those who remain in their Medicare Advantage plan pay premiums to their insurer and receive all additional benefits provided by the plan, such as vision or dental care. Original Medicare still covers hospice care if a senior remains in a Medicare Advantage Plan.
Who Is Eligible For Medicares Hospice Benefits
To qualify for Medicares hospice benefit, you must meet all the following conditions:
- Comfort care only. You must sign a statement choosing to receive hospice care instead of other Medicare-covered treatments intended to cure your terminal illness
- Death expected soon. Your hospice doctor and your regular doctor, if you have one, must certify that you are terminally ill and have a life expectancy of six months or less.
- Program authorized. You must enroll in a hospice program that Medicare has approved.
- Part A in place. You must have Medicare Part A hospital insurance.
You can get hospice care for up to two 90-day periods, followed by an unlimited number of 60-day periods. At the start of each period of care, your hospice doctor must confirm that you are still terminally ill for you to continue receiving hospice care benefits.
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Where You Get Hospice Care
The hospice benefit allows you and your family to stay together in the comfort of your home unless you need care in an inpatient facility. If your hospice team determines that you need inpatient care, they’ll make the arrangements for your stay.
If you need to get inpatient care at a hospital, your hospice provider must make the arrangements. The cost of your inpatient hospital care is covered by your hospice benefit, but paid to your hospice provider. They have a contract with the hospital and they work out the payment between them. However, if you go to the hospital and your hospice provider didnt make the arrangements, you might be responsible for the entire cost of your hospital care.
Medicare Supplement Insurance Plans And Hospice Care
Medicare coverage for hospice care can lighten the burden for terminally ill Medicare beneficiaries and their loved ones. A Medicare Supplement insurance plan might lighten that burden even more. Medicare Supplement insurance plans may cover out-of-pocket costs after Original Medicare, Part A and Part B, has paid its share of covered expenses, whether of hospice care or other medical expenses. Hospice care includes a range of services for terminally ill people. The focus is on patient comfort, not on efforts to cure the illness or prolong life. Usually a team of professionals provides care, often in the patientâs home. Hospice services also generally provide emotional and caregiving support to families.
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Medicare Costs For Hospice Care
Thankfully for patients and their families, there is little to no cost for Medicare hospice.
The only services you may need to pay for include:
It is also important to note that your monthly Medicare Part B premium doesnt go away once you start hospice care. You will need to continue paying this each month.
If you have a Medicare Advantage plan, you will also need to continue paying those premiums, unless you decide to drop the policy and stick exclusively with Original Medicare .
Do Medicare Advantage Plans Cover Palliative Care
Medicare Advantage plans are required by law to provide all of the same benefits as Original Medicare with one exception: hospice care .
However, if you have a Medicare Advantage plan, your hospice and palliative care will still be covered under Original Medicare. Remember, when you sign up for a Medicare Advantage plan, you are still technically enrolled in Original Medicare as well.
Some Medicare Advantage plans may also cover home health care items and services, such as bathroom grab bars and home meal delivery, both of which are not covered by Medicare Part A and Part B.
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Which Services Are Not Covered By Medicares Hospice Benefit
Medicare will not cover these items and services once your hospice benefit starts:5
- Treatment intended to cure your terminal illness and/or related conditions
- Prescription drugs that arent for your terminal illness or related conditions
- Care from any provider that wasnt set up by the hospice medical team
- Room and board*
- Care you get as a hospital outpatient , care you get as a hospital inpatient or ambulance transportation
*If your hospice team decides you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.6
Medicare may cover these services if your hospice team arranges it or its unrelated to your terminal illness and related conditions.7
Will My Advantage Plan Premiums Go Up When I Start Hospice
No. Even though hospice patients start receiving bothMedicare Advantage benefits and an additional hospice benefit through originalMedicare, the costs to Medicare Advantage beneficiaries remain the same.However, people with Advantage plans do need to keep paying their premiums,copays, and deductibles according to plan rules. Original Medicare pays 100%for hospice-related services, but all other healthcare is handled normally.
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Can You Stop Hospice Care
If your condition gets better or goes into remission, you may wish to end hospice care. You can stop hospice care at any point, but you must make it official: Youll need to sign a form that states the date your care will stop.
Note that you should sign a form of this kind only if you are ending hospice there are no forms with an end date when you start hospice care.
If you were in a Medicare Advantage plan, youll still be a member of that plan after you end hospice and are eligible for coverage from the plan. If youre a member of Original Medicare, you can continue with Medicare after you end hospice care.
If you have additional questions about your Medicare coverage, visit Medicare.gov or call 800-MEDICARE .
What Is Palliative Care
When someone receives a diagnosis of a life threatening illness, they may need palliative care.
Palliative care doctors and nurses provide treatments that relieve the symptoms of a health condition and improve a persons quality of life. They may provide care in the individuals home, a hospital, a nursing home, or a palliative care clinic.
Various conditions may lead to the need for palliative care, including:
This type of care involves helping improve the physical, mental, and emotional quality of a persons life. The exact care that someone receives will depend on their individual needs.
Physical support typically involves pain relief for symptoms and in completing everyday tasks that the person may have difficulty with, such as personal care and hygiene.
Palliative care professionals can also provide practical help, such as helping a person navigate treatment options or helping them work out their finances.
Mental healthcare provides support for the persons emotional and spiritual needs.
Palliative care and hospice care are related forms of support. If someone receives a diagnosis of a terminal illness and a doctor does not believe that they will survive for longer than 6 months, they may choose hospice care.
Hospice care provides the best possible quality of life for someone in their final months of life.
The different parts of Medicare cover inpatient care, outpatient care, mental health support, and necessary prescription drugs.
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What Does The Medicare Part A Hospice Benefit Not Cover
Medicare generally wonât cover any of these once you choose hospice care:
- Treatment intended to cure your terminal illness
- Prescription drugs to cure your illness
- Care from any hospice provider that wasnât set up by the hospice medical teamAll care that you get for your terminal illness must be given by or arranged by the hospice team. However, you may still be able to see your regular doctor if youâve chosen him or her to be the attending medical professional who helps supervise your hospice care.
- Room and boardMedicare doesnât cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. However, if the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility.
- Care in an emergency room, inpatient facility care, or ambulance transportationunless itâs either arranged by your hospice team or is unrelated to your terminal illness.
Does Medicare Cover Hospice
The term hospice refers to treatment, services, and care for people who have an illness and are not expected to live longer than 6 months.
Making decisions about hospice care, whether for yourself or someone you love, is not easy. Getting direct answers about what hospice costs and how you can pay for it may make a difficult decision a little clearer.
Original Medicare does pay for hospice care, as long as your hospice provider is enrolled in the program and accepts Medicare coverage. A Medicare Advantage plan will also cover hospice care.
If youre looking for specific answers about which hospice facilities, providers, and services are covered under Medicare, this article will help you answer those questions.
Medicare covers hospice once a medical doctor certifies that you have an illness that makes it unlikely you will live longer than 6 months.
To get this coverage, you must sign a statement that confirms:
- you want palliative care
- you dont intend to continue seeking treatments to cure the illness
- you choose hospice care instead of other Medicare-approved services to treat your illness
If you are receiving hospice care, that means your doctor has certified that your life expectancy is 6 months or less. However, some people defy expectations.
Medicare will pay for two 90-day benefit periods. After that, you can re-certify for an unlimited number of 60-day benefit periods. During any benefit period, if you want to change your hospice provider, you have the right to do so.
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Hospice And Medicare Advantage Plans
Hospice care is covered for all Medicare beneficiaries through Medicare Part A, including beneficiaries enrolled in a Medicare Advantage plan.
If you have a Medicare Advantage plan, sometimes called Medicare Part C, and choose hospice care for a terminal condition, you are eligible to receive hospice care coverage through Medicare Part A. This does not mean you are required to drop your Medicare Advantage plan.
Your Medicare Advantage plan continues to provide supplemental health services, such as vision or dental and Medicare Part D , that are not related to your terminal illness. Original Medicare is also available to cover any other services not related to the terminal illness care provided by the hospice. Part A covers mostly inpatient care and Part B covers mostly outpatient care.
If You Have Private Insurance
Most private insurance plans cover the full cost of hospice care and define it and its accompanying services under the same guidelines as Medicare. Unlike Medicare, however, each may have unique requirements a patient must meet before hospice care is approved. Moreover, patients with private insurance may encounter different out-of-pocket costs for certain aspects of hospice care.
Every plan is different. So contact your private insurer to determine exactly whats covered and what costs you may have.5
One caveat: No matter what your coverage, choosing high-quality hospice care can be challenging. Growth in the for-profit side of the industry has led to troubled providers with faulty management entering the field. The result can be large gaps in service, inadequate care, and even outright fraud. The Office of the Inspector General released a government report in 2019 documenting lapses in care and fraudulent schemes. Be sure you thoroughly research a hospice provider before you sign up.6
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What Is Included In Palliative Care
During hospice care, the following services and items may be rendered as a form of palliative care.
- Doctor and nursing care services
- Walkers wheelchairs, catheters and other equipment designed for comfort or convenience
- Prescription drugs used for symptom or pain relief
- Grief counseling
- Respite care
Your Costs For Hospice Care Under Medicare
Medicare Part A covers most hospice services in full, but you may have the following out-of-pocket costs:
- A maximum of $5 per prescription for drugs used to control the symptoms and pain of your terminal illness
- Up to 5 percent of the cost of inpatient respite care
- Room and board if you live in a facility that is not for hospice care, such as a nursing home, but choose to receive hospice care there
Keep in mind
You are free to stop hospice care any time you want to and then resume it if thats your wish. Medicares hospice coverage continues as long as your doctor and a hospice doctor continue to certify that youre terminally ill, even if you live longer than six months.
You can use Medicare benefits to get care for health problems that arent a part of your terminal illness, paying for any of Medicares copayments and deductibles as usual. But once you choose hospice care, you cant use your Medicare benefits to cure your terminal illness.
Original Medicare will cover your hospice benefits, even if youve chosen a Medicare Advantage plan. If you already had a Medicare Advantage plan before you started hospice care, you can choose to stay in that plan if you pay the monthly premiums. The plan can cover care not related to your terminal illness.
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