When a loved one is nearing the end of their life, decisions about care can be overwhelming. One of the most crucial decisions is whether hospice care is the right choice. Hospice provides compassionate care that focuses on comfort and quality of life, but understanding how insurance and benefits work with hospice care can be complicated. This guide is designed to help clarify hospice insurance/coverage options and ensure that you can make the best decision for your loved one’s care.

What is Hospice Care?

Hospice care is specialized care designed to provide comfort and support for individuals who are facing a life-limiting illness. It focuses on managing symptoms, pain, and emotional support for both patients and their families, rather than trying to cure the illness. The goal of hospice care is to help the patient live as comfortably and meaningfully as possible in their final months, weeks, or days of life.

 

 

What Does Hospice Care Include?

Hospice care includes a team of support

• Pain management and symptom control
• Medical equipment and supplies
• Nursing care
• Social work and counseling
• Spiritual support
• Certified nursing care for grooming and other needs
• Short-term inpatient care if needed (respite)

 

 

While Hospice is scary for some people it does provide a much more personalized option then a hospital environment. It allows for a comprehensive team to provide personalized care and support and allows yourself or your loved one to stay in their home.

Now, let’s explore how hospice care is covered.

 

How Does Hospice Care Get Paid For?  

Here’s an overview of how hospice care is typically covered:

** Over 90% of all hospice patients rely on Medicare or Medicaid service for Hospice which each are explained below:

 

 

1. Medicare Coverage for Hospice Care

Most hospice patients fall in this category. For many patients 65 and older, Medicare provides extensive coverage for hospice care through its Medicare Part A program. Here’s how it works:

• Eligibility: To qualify, the patient must be diagnosed with a terminal illness and have a life expectancy of six months or less, as certified by a doctor.
• Covered Services: Medicare Part A covers:
  • All hospice care services, including physician services, nursing care, and medications related to the terminal illness.
  • Hospice care at home, nursing facilities, or inpatient care if needed.
  • Medical supplies and equipment, like wheelchairs and oxygen therapy.
  • Pain relief and symptom management medications.
  • Counseling services for both the patient and their family.
• Costs: Medicare typically covers 100% of the costs of hospice care for eligible patients, with a few small exceptions:
  • Prescription Medications: Covered for symptoms related to the terminal illness. If a patient needs medications unrelated to the terminal illness, those costs may not be covered.
  • Inpatient Care: Medicare covers short-term inpatient care if the patient’s symptoms cannot be managed at home. This care is generally limited to 5 days at a time, and certain conditions must be met.
  • Co-payments: While most services are covered, there may be a small co-payment for outpatient prescription drugs (usually up to $5 per prescription).
    

2. Medicaid Coverage For Hospice Care

Medicaid also covers hospice care for eligible individuals, but like Medicare, the specific benefits vary by state. Here’s an overview:

• Eligibility: Eligibility is based on income and medical needs, and like Medicare, patients must have a terminal illness with a prognosis of six months or less to live.
• Covered Services: Medicaid generally covers the same services as Medicare, including home care, inpatient care, and medications related to the terminal illness.
• Costs: Medicaid generally covers hospice care at no cost or a minimal co-payment for eligible patients. However, this can vary depending on the state and the specific Medicaid plan.

Again:  Over 90% of all hospice patients rely on Medicare or Medicaid service for Hospice (https://www.medicare.gov/coverage/hospice-care)

 

3. Private Insurance Coverage

Many private health insurance plans (including those offered through employers) also cover hospice care, although the level of coverage can differ.

• Eligibility: Coverage is typically available to individuals who meet the eligibility criteria for hospice care, such as having a terminal illness with a prognosis of six months or less to live.
• Covered Services: Coverage generally includes similar services to those covered under Medicare and Medicaid, such as home care, nursing services, medical supplies, and medications.
• Costs: Some private insurance plans may require co-pays, deductibles, or limits on the number of hospice visits or days covered. It’s essential to check with the insurance provider to fully understand the costs involved.
  

 

4. Veterans’ Benefits

Veterans who qualify for care through the Department of Veterans Affairs (VA) may be eligible for hospice care coverage, often with additional benefits tailored to their needs. VA hospice services are typically provided in a hospice facility, at home, or in VA nursing homes.

• Eligibility: Veterans who are enrolled in the VA health care system and meet the criteria for hospice care are eligible for benefits.
• Covered Services: VA hospice benefits typically include home care, medications, counseling, and respite care for caregivers.
• Costs: Veterans may not need to pay for hospice services, depending on their service-connected disability status or financial need.
  

 

5. Long-Term Care Insurance

Some individuals have long-term care insurance that may help cover hospice care, especially if the patient is already in a nursing home or requires a significant amount of care.

• Eligibility: Coverage depends on the terms of the specific long-term care policy.
• Covered Services: These policies often cover hospice care as part of their benefits, though they may be limited to specific services or facilities.
• Costs: Long-term care insurance may cover some or all of the costs, depending on the policy terms.
  

 

6. Out-of-Pocket Payments

This is not a common situation, but if none of the coverage above applies and insurance is insufficient or unavailable, families may need to pay out-of-pocket for hospice care services. Some hospices may offer a sliding scale for payment based on income, or payment plans to ease the financial burden.

 

How to Determine Your Hospice Coverage

• Review your insurance policy: The best place to start is by reviewing your insurance policy to see what is covered and what your out-of-pocket costs may be.
• Talk to your hospice provider: Hospice providers are often experts in understanding insurance coverage and can assist with verifying what services are covered and what paperwork is required.
• Consult a financial advisor: If you have concerns about the cost of hospice care, a financial advisor can help explore other options or resources that may be available to you.

 

Final Thoughts

Knowing that most patients have little to zero out of pocket expenses for hospice coverage helps with understanding your or your loved one’s options and hopefully can help provide peace of mind during an emotionally difficult time. Communication is critical and having a clear understanding of patient’s benefits is important.  It’s important to communicate with your loved one’s care team, ask questions, and explore the benefits available through Medicare, Medicaid, private insurance, or veterans’ benefits to ensure that your loved one receives the care and support they need.  

 

What Actions Should I Take Next?

If you or your loved one have been advised to consider either Palliative or Hospice care, it is important to understand the options available to you. There are many companies to choose from, but it is critically important to find a company that is ethical and truly puts quality patient care at the forefront.  Hospice Fraud is a real thing so make sure you do not feel pressured and understand all the benefits you and/or your loved one is elidable to receive.

If you’re considering hospice care or palliative care for a loved one, reach out to our team to learn more about your options. We’re here to support you during this challenging time as we believe in personalized care plans and a concierge approach to patient care.  We call it “The Royal Difference”. 

Please call or email us at (480) 626-4242 or info@royalhospice.com to see what other patients families say about our services as we are very proud of our 5 star google reviews.  We will provide insight over phone from our Healthcare Advisor or will plan a time that works for you to meet with the patient and their family.  We are here for you!

You can also see videos of the Hospice process and meet our team on our YouTube channel at www.youtube.com/@royalhospice.

Our company is a proud member of NHPCO (National Hospice and Palliative Care Organization) 

Our company is ACHC Accredited.  The Centers for Medicare & Medicaid Services (CMS) only grants its coveted deeming authority designation to select national accreditation organizations that consistently exceed expectations. 

Royal Hospice is also affiliated with Vital Palliative Care (www.vitalpalliative.com) and ComForCare Home Care in Scottsdale/Phoenix area of AZ.  (www.comforcare.com/scottsdale).  This enables us to provide a Continuum of Care to support family and patient’s needs.