Understanding Medicare, Insurance Coverage & Benefits for Hospice & Serious Illness Care (Palliative Care)

Navigating Coverage Options

When a loved one faces a serious illness or declining health, understanding hospice and palliative care insurance coverage can seem daunting. Many families worry about the financial aspects of care, questioning what Medicare, Medicaid or private insurance will cover. The good news is that hospice and palliative care services are often fully or partially covered, providing relief to families during an emotionally challenging time.

This guide will lead you through the specifics of Medicare, Medicaid and private insurance coverage for hospice and palliative care – helping you understand your options and enabling you to make informed choices for care of your loved one. It is also important to remember that Lightways is a non-profit organization and cares for patients regardless of their ability to pay.

Medicare Coverage for Hospice Services

The Medicare Hospice Benefit has been in place since 1982 and is a comprehensive benefit. Medicaid typically mimics the Medicare benefit depending on whether you have joined a managed care Medicaid. Please allow us to check your Medicaid coverage.

Eligibility Requirements for Medicare Hospice Coverage:

To be eligible for Medicare’s hospice benefit, a patient needs to:

• Be enrolled in Medicare Part A.
• Have a diagnosis of a terminal illness with a prognosis of six months or fewer, as confirmed by two physicians.
• Made the decision to prioritize comfort care and forego curative therapies.Receive hospice from a licensed provider approved by Medicare and Medicaid.

For additional information, visit: Medicare Hospice Benefits

What Medicare and Medicaid Covers:

Medicare provides coverage for almost all services related to hospice and the hospice diagnosis, which can include:

• Medical care provided by the hospice medical director and nurses who focus on managing your illness as well as your pain and symptom control.
• Medications related to your care and for alleviating pain and managing symptoms.
• Medical equipment and supplies including hospital beds, mobility aids, oxygen, and anything to manage to your illness.
• Physical therapy if you are able to tolerate and have a quality-of-life goal.
• Respite care for up to five days per stay in a Medicare-certified facility. Lightways can provide this in our inpatient unit or in a contracted long-term care facility.
• Grief support for a minimum of up to 13 months following the death of a loved one. This can include workshops, groups or one of one counseling.

What Medicare and Medicaid Does Not Cover:

• Curative care like chemotherapy or radiation aimed at eradicating the disease.
• Accommodations and meals at home or in a nursing home

Medicare Coverage for Palliative Care

Palliative care, aimed at providing whole person care for patients with a serious, chronic, illness is reimbursed differently than hospice care. Rather than having a specific Medicare benefit, palliative care services are included under standard Medicare benefits in Part A (Hospital Visits) and Part B (Outpatient Care). Every organization that provides palliative care can look different. Medicaid coverage will depend on whether you have a managed care Medicaid plan. Please allow us to check your benefits.

What Medicare Includes for Palliative Care:

• Visits by a palliative care nurse practitioner or physician in the hospital, long term care facility or in your home.
• Visits by a social worker to help coordinate care and provide support.
• Referrals to home health or other specialty services.
• Some programs, such as Lightways, use telehealth for end stage cardiac and lung disease.
• Some programs, such as Lightways, provide 24 phone support with a nurse practitioner.

As palliative care doesn’t require a terminal diagnosis or discontinuation of curative treatments, patients can access both palliative and curative care at the same time under Medicare.

Private Insurance & Coverage for Hospice/Palliative Care

The majority of private insurance policies, such as those offered by employers and through the Healthcare.gov marketplace, provide coverage for hospice and palliative care, although the extent of coverage can vary.

What to confirm in a Private Insurance Policy:

• Network providers – certain plans require care from hospice providers within the network.
• Deductibles and copayments – in contrast to Medicare, private insurance might involve expenses that come from your own pocket.
• Restrictions on services – some plans might limit coverage for specific treatments or medications.
• Families should allow us to contact their insurance company to determine their benefits.