After your loved one has been diagnosed with a terminal illness and begins the end-of-life journey, it can be very difficult to initiate a talk about care options. Unfortunately, many people avoid the conversation about end-of-life care not only due to death being an uncomfortable topic, but also because of the fear of potentially high costs and the financial burden it may put on them and their family.
Your loved one can complete the end-of-life journey in comfort and dignity without the fear of hospice care being a financial strain.
Through the multitude of federal, state, and private coverage options, hospice care is made affordable, often resulting in little to no cost for you, your loved one, or family. Understanding the options available to your loved one through these programs can be critical in communicating that your loved one’s care will be of no financial burden. Your loved one can complete the end-of-life journey in comfort and dignity without the fear of hospice care being a financial strain.
Medicare and the Medicare Hospice Benefit
Medicare is the federal health insurance program for United States citizens, or permanent residents, 65 years old and older. Medicare coverage can also be provided to people with permanent kidney failure and certain younger people with qualifying disabilities.
Medicare itself is divided into four different parts that correspond to different types of medical care needs.
Medicare Part A
Medicare Part A is insurance that helps cover the costs associated with being placed into:
Nursing home care
Skilled nursing facility care
Home health services
Medicare Part A is very rarely paid for, as many people qualify for free Part A coverage as a result of working, or a spouse working, for at least 10 years in the United States and paying Medicare taxes.
Medicare Part B
Medicare Part B is medical insurance and helps cover the costs associated with doctor’s visits, medical equipment, outpatient hospital care, and other services.
Medicare Part C
Medicare Part C concerns Medicare Advantage plans. Medicare Advantage plans offer all Part A and Part B benefits and include additional offerings such as vision, dental, and hearing, with some plans including prescription drug coverage as part of their offerings.
Medicare Part D
Medicare Part D is prescription drug coverage. Part D is a standalone program offered by private Medicare-approved plans. Many Part D offerings are bundled with Part A and Part B to form Medicare Advantage plans.
Beginning in the 1980’s, the federal government instituted the Medicare hospice benefit program. The Medicare hospice benefit is designed to provide the terminally ill with a dignified, comfortable, and peaceful end of life without an overwhelming financial burden. The Medicare hospice benefit is by far the most popular form of payment for hospice services, accounting for payment coverage for more than 85% of hospice patients.
Qualifying for the Medicare Hospice Benefit
If your loved one wishes to receive hospice care and have the costs covered by the federal Medicare hospice benefit program, there are a series of requirements that must be met to determine eligibility.
Medicare Part A
Your loved one must have Medicare Part A coverage to quality for the Medicare hospice benefit.
Certification of terminal illness
Your loved one’s primary physician and the hospice’s medical director must certify that your loved one has 6 months or less to live.
Acceptance of palliative care
Your loved one, your loved one’s family, or the person legally designated to speak on your loved one’s behalf, must state the acceptance of palliative care instead of seeking curative measures for the terminal illness.
Election of hospice care
Your loved one must formally elect to pursue hospice care with a specific hospice organization.
After meeting the qualification requirements, your loved one’s hospice benefits are broken up into benefit periods. There is a first 90-day benefit period, a second 90 day period, and then unlimited 60-day periods thereafter. After the end of each benefit period, your loved one must be recertified for terminal illness.
If your loved one no longer wishes to receive hospice care, your loved one can elect to stop hospice coverage at any time. Your loved one’s Medicare coverage will revert to the plan they had prior to selecting hospice care, and they can re-enter hospice care provided that the qualifications for the Medicare hospice benefit are still met.
Costs Covered by the Medicare Hospice Benefit
Upon qualification, and after selection of a hospice program that best fits your loved one’s needs, the Medicare hospice benefit covers many of the costs associated with your loved one’s end-of-life care. Your loved one’s original Medicare coverage will continue to cover the costs for health problems that aren’t directly associated with the terminal illness.
Your loved one’s hospice team includes highly-trained nursing staff that provide attentive care and pain management. The nursing staff can also assist in instructing your loved one’s at-home caregiver, or long-term care facility staff, concerning how to best provide optimal comfort and care.
If your loved one requires the use of a piece of equipment, such as a walker, cane, wheelchair, or hospital bed, the Medicare hospice benefit covers the cost of renting these items. This medical equipment is then returned upon your loved one's death, or should your loved one no longer require the equipment.
Providing comfort and care for your loved one may require the use of medical supplies, such as catheters or bandages. These are fully covered under the Medicare hospice benefit.
Medications prescribed to your loved one by the hospice physician, to manage the pain and symptoms associated with terminal illness, are fully covered.
Speech, physical, and occupational therapies
Non-medicinal forms of treatment are covered, such as speech therapy and physical therapy, and offer your loved one comfort for the whole person.
Social work services
The hospice social worker provides initial and ongoing psychosocial assessments of your loved one and family, and creates a psychosocial plan of care.
Bereavement counselors not only provide comfort, support, and guidance for you and your family, but also help your loved one work through the grief associated with death.
Short-term inpatient care
If your loved one’s condition temporarily requires the resources of an inpatient facility, this cost is covered by the Medicare hospice benefit
Short-term respite care
The role of a caregiver to a terminally ill loved one is demanding and, over an extended period of time, can become wearisome and exhausting. To help prevent caregiver burnout, your loved one can be placed in an inpatient care facility for up to 5 days at a time to allow the caregiver time to recuperate and rest.
Nutritional and dietary services
Your loved one’s hospice care team can provide insight as to what dietary restrictions might befall your loved one due to terminal illness and what foods may best facilitate a higher quality of life and comfort.
Home health aide services
The home health aide assists you and your loved one by providing light housekeeping duties and personal care needs.
Costs that the Medicare Hospice Benefit Does Not Cover
While the Medicare hospice benefit is designed to provide your loved one with an affordable means of end-of-life care, there are medical treatments and costs that are not covered by the hospice benefit program.
Medicare will not cover any costs associated with treatments, prescriptions, or procedures that are designed to help cure your loved one’s terminal illness.
Care not provided by or arranged by the hospice care organization
All care that your loved one receives for their terminal illness and related ailments must be provided by or arranged by the hospice organization that was declared in the notice of election. Your loved one's current physician, however, can be designated as the attending physician, and can continue to be visited by your loved one and collaborate with your loved one's hospice medical director and interdisciplinary team.
Emergency room care unrelated to the terminal illness
Emergency care facilities may only be covered if they are necessitated by your loved one’s hospice team; however, an out-of-pocket copayment amount may be required in these cases.
Inpatient facility care unrelated to the terminal illness
Short-term inpatient facility care is only covered by Medicare if it is recommended by your loved one’s hospice team and related to the terminal illness.
Non-emergency ambulance use can be covered by Medicare if the transportation is necessary to treat or diagnose your loved one’s condition and a physician has provided a statement stating that ambulance transportation is necessary.
Room and board costs
While hospice services can be provided no matter where your loved one calls home, the Medicare hospice benefit does not cover the costs of room and board.
Potential Out-of-Pocket Costs under the Medicare Hospice Benefit
While the Medicare hospice benefit program covers the vast majority of costs associated with your loved one’s end-of-life care, there are certain costs that you or your loved one may be responsible for while receiving hospice care.
Prescription drug costs
The medications prescribed for your loved one’s pain and symptom management require a copayment of $5.00 (USD) or less.
Inpatient respite care
While the majority of this cost is covered by Medicare, you may be required to pay 5% of the Medicare-approved amount. Contacting your loved one’s hospice organization can greatly aid in understanding what portion of the inpatient respite costs, if any, that you may be responsible for.
Room and board charges
If your loved one receives hospice care at a nursing home or other long-term care facility, the room and board charges will not be covered by the Medicare hospice benefit. If you have any questions concerning Medicare’s coverage for a prescription, treatment or service, contact your hospice organization to ensure the costs are covered prior to receiving the service.
Medicaid and the Medicaid Hospice Benefit
Medicaid is a joint operation between the federal government and state governments that is designed to provide free or low-cost health coverage to low income families, pregnant women, those with disabilities, and the elderly. Beginning in the 1980’s, and following the creation of the Medicare hospice benefit by Congress, states could choose to include hospice benefits for the terminally ill within their state Medicaid programs.
Medicaid coverage can be obtained and used alongside your loved one’s existing Medicare coverage. Electing to use the medicaid hospice benefit does not eliminate Medicaid coverage for symptoms or conditions not associated with the terminal illness.
Qualifying for the Medicaid Hospice Benefit
While each state’s Medicaid program may have variances concerning eligibility, the majority of states require the following be met in order to qualify for the Medicaid hospice benefit:
Certification of terminal illness
Your loved one’s physician must certify that your loved one is terminally ill.
Acceptance of palliative care
Your loved one, your loved one’s family, or the person legally designated to speak on your loved one’s behalf, must state that they are accepting palliative care instead of seeking curative measures for their terminal illness. If your loved one is under the age of 21, however, curative treatments can still be pursued while receiving hospice care under your state’s Medicaid hospice benefit.
Election of hospice care
Your loved one, your loved one’s family, or the person legally designated to speak on your loved one’s behalf, must officially state your choice to pursue the hospice benefit by signing a hospice election form.
Statement of reduced life expectancy
Each time your loved one’s physician reviews your loved one’s Medicaid eligibility, the physician must certify that your loved one’s life expectancy is reduced, as defined by state guidelines, as a result of the terminal illness.
State Medicaid benefits are required by federal law to last at least 210 days. Some states may divide this total time into benefit periods to help coordinate care. You can verify your state’s Medicaid benefits and how long the benefit periods last with your state’s Medicaid agency.
Costs Covered by the Medicaid Hospice Benefit
Medicaid’s coverage of hospice care services is very similar to Medicare, as both Medicaid and Medicare hospice benefits seek to make receiving hospice care extremely affordable so as to best facilitate a comfortable and peaceful end-of-life experience.
Most Medicare hospice benefit services
Most states model their Medicaid hospice benefit coverage after the Medicare hospice benefit program; however, contacting your state’s Medicaid agency is the best way to know what all services are covered by your state’s Medicaid program.
Room and board charges
Medicaid will cover the costs of your loved one’s room and board if your loved one is a resident of a long-term care facility or other qualifying assisted living facility. This coverage is unique to Medicaid and is not offered within the Medicare hospice benefit program.
Visits to physicians who specialize in your loved one’s terminal illness
While this option varies from state to state, Medicaid can cover the costs of physicians who specialize in your loved one’s terminal illness and can provide you and your loved one with unique insights as to how to best attain the utmost comfort.
Costs not Covered by the Medicaid Hospice Benefit
As the Medicaid hospice benefit is a provision of the state, the services covered for your loved one’s end-of-life care will vary from state to state. Many states, however, model their coverage and non-coverage of services by the federal Medicare model. This often excludes coverage of curative treatments and other services not related to your loved one’s terminal illness.
To contact your state’s Medicaid agency for information on the Medicaid hospice benefit and what costs may not be covered, simply select your state to get started.
Private insurance plans protect you from paying the full costs of medical services when you are sick or injured. It is usually provided by your loved one’s employer, retirement program, or covered personally by your loved one via one of the many health insurance providers across the country.
The majority of private insurance plans offer coverage for hospice and other end-of-life care services. These plans often cover the full cost of the services provided by your loved one’s hospice organization.
Qualifying for Private Insurance Hospice Coverage
Many private insurance providers offer some form of coverage for hospice care. Your loved one's insurance provider, however, may have a unique set of qualifications that your loved one must meet before receiving hospice care benefits. Inquiring concerning these qualifications can offer clarity when considering what hospice organization is the best choice for your loved one. Most private insurance providers, at a minimum, require that your loved one meet two qualifications for hospice care.
Certification of terminal illness
Both your loved one’s attending physician and the hospice’s medical director must certify that your loved one is terminally ill and has a reduced life expectancy of less than 6 months. Your loved one’s private insurance, however, may have different guidelines that allow for qualification for hospice care within a timeframe much sooner than the last 6 months of life.
Election of hospice care
Your loved one and/or family must be aware of the prognosis of terminal illness and elect to not seek curative measures.
Coverage of Costs under Private Insurance Hospice Coverage
While the majority of private insurances model their coverage after the federal Medicare hospice benefit program -- covering the entirety of hospice costs -- private insurance coverage for hospice services may vary. To ensure you fully understand what services your loved one’s coverage will provide and what costs you or your loved one may be responsible for, contact the insurance provider concerning your loved one’s hospice plan. During your discussion with the insurance provider, be sure to ask:
"What services are covered by the policy’s hospice plan?"
Confirming what services are covered, and not covered, by your loved one’s insurance policy provides peace of mind in knowing what costs are taken care of.
"What out-of-pocket expenses might my loved one be responsible for?"
Understanding what copayments or deductibles that your loved one may be responsible for can greatly aid in planning for your loved one’s costs of hospice care.
Charity care is hospice care that is provided by the hospice organization free of charge to patients who are unable to qualify for Medicare, Medicaid, or private insurance, and lack the resources to cover the costs of hospice care. Charity care funds are often provided by the hospice organization themselves, charitable donations, grants, or other community sources.
Qualifying for Hospice Charity Care
If you and your loved one are unable to provide for the costs of hospice care, your loved one’s request for hospice care cannot be rejected as long as they still meet the Medicare qualifications for hospice care. Under Medicare law, your loved one cannot be denied hospice care because of inability to pay.
Though your loved one’s hospice organization is required to send statements for the care and services provided, you, your loved one, and your family are under no judgement or pressure if you are unable to pay. Your loved one’s quality of care will not be diminished or reduced in any way.
A Dignified, Peaceful, and Comfortable End-Of-Life Journey
Regardless of your financial situation, the holistic end-of-life care of hospice is available to your terminally ill loved one. While having the hospice talk can prove difficult, helping your loved one understand that quality care -- focused on providing comfort for the whole person -- is readily available and affordable can greatly relieve anxiety surrounding thoughts of being a financial burden. The affordability of hospice, and its patient-centered care philosophy, provides your loved one with a dignified, peaceful, and comfortable end-of-life journey.