An important aspect of end-of-life planning is end-of-life health care. Great advances in medical technology have made it possible to extend life, and at the same time, have created philosophical quandaries about quality of life and a patient’s right to choose or refuse life-sustaining measures. In this context hospice and palliative care were developed, which offer comfort care when treatment may no longer be effective or best for that person. Moreover, the patient has the right to choose palliative care and hospice but should also be aware of what their insurance will cover. 

Hospice and palliative care ...  offer comfort care when treatment may no longer be effective or best for that person.

The insurance industry has traditionally reimbursed for services they deemed “medically necessary,” following a curative philosophy of treatment. Over time, the industry – including the Center for Medicare and Medicaid Services, the largest insurance payer in the U.S. – has come to acknowledge the benefit of hospice and palliative care services. Medicare offers a hospice benefit under Part A and may cover palliative care services in some circumstances under Part B as well. 

A person is eligible for hospice benefits under Medicare if they have a life expectancy of six months or fewer, as certified by a doctor. The person must also be enrolled in Medicare Part A to be eligible for hospice benefits paid by Medicare. The election into hospice is not required – it’s entirely optional – and requires an affirmative election in writing signed by the patient. By electing into hospice, a patient acknowledges that Medicare will no longer cover treatment or medications intended to cure the person’s terminal illness and related conditions.

The Medicare hospice benefit, typically provided in the person’s home, includes a comprehensive care team consisting of a doctor, nurse, social worker, physical and occupational therapists, counselors, hospice aides, chaplains, and volunteers. Other covered hospice benefits include 24/7 crisis response, respite care, durable medical equipment and supplies, prescription drugs for symptom control and pain relief, and grief counseling for family members and caregivers after a person passes away. A person’s hospice team will work with the person to set up a plan of care to ensure all needs are met.

Hospital inpatient stays, emergency room visits, and ambulance transportation are typically not covered under hospice, unless they are written into the person’s hospice plan of care and arranged by the hospice provider. For example, if a person’s pain cannot be managed in their home setting, the hospice plan of care could include an overnight stay in a hospital so that more intensive interventions to better control or minimize pain can be used. An exception to this rule is the five-day caregiver respite benefit, which provides inpatient care on an occasional basis.

Out-of-pocket costs under hospice care are low. The Medicare Part A deductible does not apply to hospice benefits and services. A person enrolled in hospice pays 5 percent coinsurance on medications up to a maximum of $5 per drug, and 5 percent coinsurance for short-term inpatient respite care. If a person enrolled in hospice chooses to receive care or treatment for health problems that are not related to the terminal illness, that would still be covered under Original Medicare and deductibles and coinsurance would apply.

Sometimes people think entering hospice means they will die soon afterwards, so they wait to take advantage of these benefits. However, a person can remain in hospice longer than six months if their medical provider recertifies that they remain terminally ill. Likewise, a person can opt-out of hospice at any time. Sometimes the person’s health improves, or an illness goes into remission, so the person may no longer need hospice care. Electing the benefit as soon as a person is qualified can bring relief to the person and family sooner, improving quality of life.

Palliative care is not an insurance benefit under Medicare. Rather, it’s a term to describe comfort care, whether or not that is in the context of hospice care. Palliative care focuses on providing an individual who has a serious illness with relief from pain and other symptoms. The goal is to improve quality of life. Palliative care is available at any stage of a serious illness. A multidisciplinary team of doctors, nurses, and other specialists tend to the physical, spiritual, and emotional needs of the individual and their family. Palliative care can be provided wherever you reside. Palliative care outside of the Medicare hospice benefit can be covered under Medicare Part B.

As unpleasant as it may be to think about this topic, it can be comforting to know there are choices for end-of-life health care which may be covered by Medicare, such as hospice and palliative care. 

Portions of this article are reprinted with permission from Greater Wisconsin Agency on Aging Resources (GWAAR). For more information, contact the Aging and Disability Resource Center (ADRC) of Eau Claire County, 721 Oxford Ave., Room 1130, Eau Claire, WI 54703-5481. Call (715) 839-4735 or (888) 338.4636, visit www.eauclaireadrc.org, or email adrc@co.eau-claire.wi.us.