Medicare
What Medicare Covers
Medicare will cover the hospice care you get for your terminal illness, but it must be from a Medicare-approved hospice program.
Important: Medicare will still pay for covered benefits for any health problems that aren’t related to your terminal illness.
Medicare covers the following hospice services for your terminal illness and related conditions:
- Doctor services
- Nursing care
- Medical equipment (such as wheelchairs or walkers)
- Medical supplies (such as bandages and catheters)
- Drugs for symptom control or pain relief (may need to pay a small copayment)
- Hospice aide and homemaker services
- Physical and occupational therapy
- Speech-language pathology services
- Social worker services
- Dietary counseling
- Grief and loss counseling for you and your family
- Short-term inpatient care (for pain and symptom management)
- Short-term respite care (may need to pay a small copayment)
- Any other Medicare-covered services needed to manage your pain and other symptoms, as recommended by your hospice team
Respite Care
You can get inpatient respite care from a hospice if your usual caregiver (such as a family member) needs a rest. During this time, you will be cared for in a Medicare-approved facility, such as a hospice inpatient facility, hospital, or nursing home.
What Medicare Won’t Cover
When you choose hospice care, Medicare won’t cover any of the following:
- Treatment intended to cure your terminal illness
You should talk with your doctor if you’re thinking about getting treatment to cure your illness. As a hospice patient, you always have the right to stop hospice care at any time.
- Prescription drugs to cure your illness rather than for symptom control or pain relief
- Care from any hospice provider that wasn’t set up by the hospice medical team
You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice medical team. You can’t get the same type of hospice care from a different provider, unless you change your hospice provider.
- Room and board
Medicare doesn’t cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice residential facility. However, if the hospice medical team determines that you need short-term inpatient or respite care services that they arrange, your stay in the facility is covered. You may have to pay a small copayment for the respite stay.
- Care in an emergency room, inpatient facility care, or ambulance transportation, unless it’s either arranged by your hospice medical team or is unrelated to your terminal illness
Note: Contact your medical hospice team before you get any of these services, or you might have to pay the entire cost.
What You Pay for Hospice Care
Medicare pays the hospice provider for your hospice care. You will have to pay the following:
- No more than $5 for each prescription drug and other similar products for pain relief and symptom control.
- 5% of the Medicare-approved amount for inpatient respite care.
For example, if Medicare pays $100 per day for inpatient respite care, you will pay $5 per day. You can stay in a Medicare-approved hospital or nursing home up to 5 days each time you get respite care. There is no limit to the number of times you can get respite care. The amount you pay for respite care can change each year.
Hospice Care if You’re in a Medicare Advantage Plan
All Medicare-covered services you get while in hospice care are covered under Original Medicare, even if you’re in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan. A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. However, if your plan covers extra services not covered by Original Medicare (like dental and vision benefits), then your plan will continue to cover you for these extra services. If you choose to stay in your Medicare Advantage Plan while getting hospice care, you must continue to pay your plan’s monthly premium.
Care for a Condition Other than Your Terminal Illness
You should continue to use Original Medicare to get care for any health care needs that aren’t related to your terminal illness. You may be able to get this care from the hospice medical team doctor or from your own doctor. The hospice medical team determines whether any other medical care you need is or isn’t related to your terminal illness so it won’t affect your care under the hospice benefit.
You must pay the deductible and coinsurance amounts for all Medicare-covered services. You must also continue to pay Medicare premiums, if necessary.
For more information about Original Medicare, Medicare Advantage Plans, and other Medicare health plans, look in your copy of the “Medicare & You” handbook mailed to every Medicare household in the fall. If you don’t have the “Medicare & You” handbook, you can view it by visiting www.medicare.gov/Publications/Pubs/pdf/10050.pdf.
Information about Medigap (Medicare Supplement Insurance) Policies
If you have Original Medicare, you might have a Medigap policy. Your Medigap policy still helps cover health care costs for problems that aren’t related to your terminal illness. Call your Medigap insurance company for more information. To get more information about Medigap policies, visit www.medicare.gov/Publications/Pubs/pdf/02110.pdf to view or print the booklet “Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare.” You can also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
How Long You Can Get Hospice Care
You can get hospice care as long as your doctor and the hospice medical director (or other hospice doctor) continue to certify that you’re terminally ill and have 6 months or less to live if the disease runs its normal course. 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 you’re terminally ill.
Important: Hospice care is given in periods of care. You can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period of care, the hospice medical director or other hospice doctor must recertify that you’re terminally ill, so you can continue to get hospice care. A period of care starts the day you begin to get hospice care. It ends when your 90‑day or 60‑day period ends.
Stopping Hospice Care
If your health improves or your illness goes into remission, you no longer need hospice care. Also, you always have the right to stop getting hospice care at any time for any reason. If you stop your hospice care, you will get the type of Medicare coverage you had before you chose a hospice program, such as treatment to cure the terminal illness. If you’re eligible, you can go back to hospice care at any time.
Example: Mrs. Jones has terminal cancer and received hospice care for two 90-day periods of care. Her cancer went into remission. At the start of her 60-day period of care, Mrs. Jones and her doctor decided that, due to her remission, she wouldn’t need to return to hospice care at that time. Mrs. Jones’ doctor told her that if she becomes eligible for hospice services in the future, she may be recertified and can return to hospice care.
Your Medicare Rights
As a person with Medicare, you have certain guaranteed rights. If your hospice program or doctor believes that you’re no longer eligible for hospice care because your condition has improved and you don’t agree, you have the right to ask for a review of your case. Your hospice provider should give you a notice that explains your right to an expedited (fast) review by an independent reviewer hired by Medicare, called a Quality Improvement Organization (QIO). If you don’t get this notice, ask for one. For more information about your Medicare rights, visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view or print the booklet “Your Medicare Rights and Protections.” You can also call 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1-877-486-2048.
If you have a complaint about the hospice that is providing your care, contact your State Survey Agency. Visit www.medicare.gov, and select “Ombudsman,” then “Inquiries and Complaints” to find the number of your State Survey Agency. You can also call 1-800-MEDICARE, and ask for your State Survey Agency’s phone number.
Medicaid
Medicaid is a medical assistance program that helps many people who can’t afford medical care pay for some or all of their medical bills. The state of Georgia’s Medicaid is administered by the Georgia Department of Community Health (DCH) and pays medical bills with State and Federal tax money.
Can I have both Medicaid and Medicare at the same time?
It depends. If you receive Supplemental Security Income (SSI) from the Social Security Administration, you are automatically eligible for Medicaid and often receive Medicare as well. If you receive both Medicaid and Medicare, Medicaid will pay your Medicare premium, co-payments and deductibles. If you have both Medicare and Medicaid, you should show both cards to your medical care provider each time you receive services.
Medicare and Medicaid programs offer hospice benefits for patients who need end-of-life care. The rules work in a similar fashion for both, although the Medicaid version of the program will cover more of the benefits than the federal program will. The rules for bother programs are similar, although there are slight variations for each version. Regardless, the basics of how to get the benefits are the same.
Establishing a plan of Care
Before a Medicaid client can receive hospice benefits, a plan of care must be established for the patient. This includes doctors’ services, counseling, plans for treatment and any drugs that the person must need. Hospice care, by its nature is not intended to last for a long period of time. While the prospect is not very pleasant, the patient may also receive end-of-life counseling as part of his overall treatment. A caseworker may help arrange all this if a client feels that hospice care is necessary. Medicaid also pays for nursing home coverage after a person’s Medicare benefits run out. Care in a long-term nursing facility and Medicaid benefits are not the same thing as hospice benefits. Not everyone who needs care in a nursing home stays in the home for the rest of their life.
Tricare
Tricare is the health benefits program for military personnel and retirees. Hospice is a fully covered benefit under TRICARE. Only Medicare-certified hospices can provide for the TRICARE hospice benefit, therefore it is important that patients and family check with their Health Benefit Advisor or Health Care Finder to help them locate a qualified hospice agency.
Private Insurance
Most insurance plans issued by employers and many managed care plans offer a hospice benefit. In most cases, the coverage is similar to the Medicare benefit, although there may be some variations between employers.
Private Pay
If insurance coverage is unavailable or insufficient, the patient and the patient’s family can discuss private pay and payment plans.
