Who Pays for Hospice Care?
by Eve B. Scheffenacker
When the first hospice care programs started in the 1970s, the medical profession and the public viewed them with some misgiving. Doctors, patients, and their families didn't want to declare a disease incurable and, worse, terminal.
Pain management, which is central to the hospice approach to care, was not the subtle art it is today. Doctors and their patients often accepted pain as an inescapable part of certain diseases.
Besides, in many of the early hospice programs, there was no "there" there. They operated out of rented office space, caring for patients in their homes with volunteer staff. They didn't have the buildings and equipment that might have legitimized them in the eyes of the public and medical profession.
Now, three decades later, hospice care is an accepted form of treatment. Close to 4,000 programs operate around the country, compared with the one program that existed in 1974. As the number of programs and patients has increased, the profile of the typical hospice patient has changed. Most of the patients in the early hospice programs had some form of cancer. Now, more than half of hospice patients are diagnosed with conditions other than cancer--end-stage heart disease and kidney disease, dementia, and lung disease are the most common diagnoses. And today, more than 64% of hospice patients are age 75 or older.
These trends are of more than passing interest to those of us who worry about the cost of end-of-life care. The change in attitudes about hospice care and the larger, older, and more diverse patient population have led to another change--the coverage available for hospice care from insurance and medical benefit plans.
For once, the news about health-care costs is good: You probably don't have to bankrupt yourself to pay for hospice care. Most private insurance and employer-sponsored medical plans, as well as Medicare and Medicaid, cover hospice care. Here's what you can expect if you or a family member wants to enter a hospice program. Most private insurance and employer-sponsored plans cover hospice care.
General information
No matter what kind of coverage you have, you and/or the hospice program must meet certain criteria.
A doctor must certify that you are terminally ill and that your life expectancy is six months or less. Don't be alarmed by the six-month limit; it's part of many standard definitions of terminal illness, assuming a disease follows the expected course. No one is bound by it, the patient least of all. Your hospice won't put you out if you live longer. And insurance plans won't cut off after six months unless you have reached a benefit limit.
You will not receive any medical treatment intended to cure your condition. The hospice will deliver medical and supportive care only to provide comfort and pain relief. If you decide to resume curative treatment, you must leave the hospice program.
The hospice program must be licensed locally and have Medicare approval. For a list of Medicare-approved hospice programs in your area, contact the National Hospice Organization Hotline at 800-658-8898.
Covered hospice services usually include the services of doctors, nurses, medical social workers, and home-health aides; physical therapy, medical supplies, and medications. Some plans also cover counseling for the patient's family.
Hospice benefits do not cover room and board charges for hospital, nursing home, or other residence facility. Most hospice patients are cared for at home, and hospice team members support family and other caregivers. Plans usually do cover brief inpatient stays, but only to give a patient's caregiver a respite or if the patient's pain or discomfort is too great to take care of at home.
Many hospices have special funds to help patients cover their costs.
Private insurance
If you have private medical insurance or belong to an HMO or an employer's benefit plan, you likely have hospice-care coverage. These plans usually limit coverage by setting a dollar limit on benefits or limiting the number of covered home visits.
Medicare
Medicare has provided a hospice care benefit since 1982. It's now the primary payer for almost two-thirds of hospice patients, so most hospice policies and programs are designed to meet Medicare requirements. Under Medicare, you must elect hospice care in writing if you want it. The hospice benefit replaces other Medicare coverage, including Part D for prescription drugs--but only for services related to the terminal disease. Regular Medicare benefits are available for any medical treatment that's not related to the hospice diagnosis.
Medicare pays the hospice a set daily amount per patient, and the payment amount is well below the hospice's cost. You cannot be charged for the difference. However, the hospice can require a $5 copayment for medication and a 5% copay for any inpatient care.
Medicare measures the duration of hospice benefits using "benefit periods." The patient can elect the hospice benefit for two 90-day periods, and then for an unlimited number of 60-day periods. The patient can use the benefit periods consecutively, or take time between the periods. For example, if a person's condition is stable, hospice programs and Medicare allow him or her to sign out of the program and return again if the condition worsens. The patient's doctor must re-certify the condition as terminal at the beginning of each period. Medicare is the primary payer for almost two-thirds of all hospice patients.
Medicaid
Medicaid may be the only benefit option for people who have little or no insurance and are not eligible for Medicare. The problem is that the patient must "spend down" his or her assets to become eligible. Since 1986, 47 states have developed their own Medicaid hospice benefits. The requirements and benefit structure are similar to those of Medicare, though they may differ from state to state.
Your hospice
Your hospice also can help you with financing as well.
First, many hospices have special funds to help patients cover their costs. Gifts from the community generally support these funds. Each hospice can set its own policies for determining a patient's level of need. Also, hospice staff can help you identify local social and government programs that provide funding or special services.
Quality hospice care, unlike long-term care and nursing-home care, is one kind of end-of-life care that's within reach of most people who need and want it.
April 17, 2006
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