As a Medicare agent, one of your key responsibilities is guiding seniors through difficult and often confusing parts of their coverage—hospice care being a prime example. Many clients (and their families) aren’t sure what hospice entails or how it’s paid for through Medicare. Your ability to explain this clearly can make a major difference during an emotionally challenging time.
What Is Hospice Care?
Hospice is specialized care designed for individuals who are terminally ill and no longer seeking curative treatment. The focus shifts to comfort, pain management, and quality of life. It’s about supporting both the patient and their loved ones during the final phase of life.
Services under hospice include medical care, pain management, and spiritual and emotional support for quality of life. It also provides support for family caregivers during this difficult time. Hospice care is typically administered in the patient’s home, but can also be provided in hospice facilities, hospitals, or nursing homes.
What does Medicare cover for Hospice care?
Medicare provides hospice benefits for beneficiaries on Original Medicare. The care must be from a Medicare approved Hospice provider and must be related to the terminal illness. Medicare covers everything needed for palliative care of the terminal illness and related conditions.
Covered hospice services may include:
- One-time hospice consultation prior to deciding on Hospice
- Doctor and Nurse services
- Medicare equipment and Supplies
- Prescription drugs
- Hospice aide and homemaker services
- Physical, occupational, and speech-language pathology service
- Social worker and grief and loss counseling for patient and families
- Dietary Counseling
- Short-term inpatient care
- Short-term respite care
The Costs for Hospice Under Medicare
Once admitted to hospice care, Medicare will pay most of the above listed services without a deductible. You do need to continue your monthly Part A and Part B premiums. Most people qualify for Premium-free Part A, but if you did not have enough work credits then you will need to continue to pay your Part A premium to continue to receive hospice coverage.
The hospice services that require a copay are:
- Prescription drugs given to manage pain and symptoms have a copay of $5 per prescription. Part D does not cover the drugs administered through hospice care. This means you do not follow the copay schedule of your drug plan for prescriptions related to your illness.
- If you need inpatient respite care, you will pay 5% of the Medicare-approved amount when you receive care in a Medicare-approved facility.
Services Medicare will not pay under hospice
As mentioned, hospice coverage includes only palliative care to provide comfort and manage a patient’s pain from a terminal illness. It will not cover care for any condition that is not related to your terminal illness. This means you can receive care for other conditions, but the hospice benefit won’t cover it. You would revert to using whichever Medicare plan you have for their Medicare coverage.
For example, if you break your arm due to something unrelated to your terminal illness, hospice will not cover the treatment. You would need to seek care through your regular Medicare plan. Your costs are based on your plan or Original Medicare, depending on which one you have.
How hospice benefits work with a Medicare Advantage or Medicare Supplement plan
When admitted to hospice, the benefits and costs highlighted above are covered and paid by Original Medicare, not the plan. However, beneficiaries have a right to stay in their plan if they have a Medicare Advantage or a Medicare Supplement. These plans can still cover any health care needs that are not part of the terminal illness. Essentially, they will would use the hospice benefit for anything related to their terminal illness, and then the plan for anything outside of that.
The care received outside of hospice benefits would be subject to the plan’s cost sharing. If they have a Medicare Advantage plan, this means using the network providers and paying the plan deductible, copays, or coinsurance. The Medicare Advantage plan is not billed for any hospice services.
If they have a supplement, then the supplement may pay their portion of the limited hospice charges for drugs and respite care. If they need care outside of hospice, then they would use their Original Medicare and Medicare Supplement plan to pay for services. They will be subject to any deductibles or costs outlined in the Medicare supplement.
Their hospice drugs are not billed under their Part D prescription drug plan. But if ythey need any prescriptions that are not related to their terminal illness, then their Part D plan will kick in to cover them.
If they only have Original Medicare when entering hospice, then Original Medicare would cover care for conditions not associated with their terminal illness. The costs would be subject to normal Part A and Part B deductibles and coinsurance.
Example Medicare Advantage Plan Member
Jane, a 68-year-old with a Medicare Advantage HMO plan, is diagnosed with terminal cancer. Upon electing hospice care, her hospice services are covered by Original Medicare. Jane decides to keep her Medicare Advantage Plan because it is a $0 premium. She comes down with a urinary tract infection unrelated to her condition while in hospice. She needs to use her Medicare Advantage plan to obtain care for the infection.
When to Reassess
Patients can continue receiving hospice care beyond the initial six months if a doctor recertifies that they are still terminally ill. They can also choose to stop hospice care at any time to resume standard Medicare coverage and later return to hospice if needed.
Your Role as a Trusted Guide
Hospice is a sensitive topic, and many seniors and families feel overwhelmed by it. As their agent, your guidance can provide clarity. Helping them understand their options allows them to make informed choices with peace of mind. Making sure you understand how their Medicare Advantage and Supplement plan work with Hospice is important when giving them advice if they should keep or drop a plan.
Need more agent training to better help your clients maximize their benefits and coverage? Give us a call!