Hospice
Check Medicare Eligibility
In California, Medicare pays for a growing portion of hospice costs — more than 82% of it. The rise is partly due to the increasing popularity of hospice care, and also to the increasing number of eligible hospice services available. But there are limits on the amount of care that is covered — and Medicare also imposes specific requirements on who and what services it will cover.
Who Is Covered
Medicare is a federal health insurance program for people age 65 and older, some disabled people under 65, adults who receive Social Security payments, and those with end-stage renal disease. Medicare coverage has two parts:
Part A hospital insurance pays for most inpatient hospital care, some inpatient skilled nursing home care, some home health care, and hospice care.
Part B pays for doctors' services, outpatient hospital care, outpatient physical and speech therapy, some home health care, ambulance services, and some medical equipment and supplies. Those who don’t automatically qualify for Medicare can get its coverage by paying a premium.
For hospice care to be covered by Medicare Part A:
- The provider must be certified by Medicare;
- A doctor and the hospice medical director must verify that the patient is terminally ill — meaning that he or she probably has less than six months to live if the illness runs its normal course; and
- The patient or his or her medical representative must sign a statement choosing hospice care instead of standard Medicare-covered benefits — although Medicare will continue to cover health problems unrelated to terminal illness.
Medicare generally covers an initial 90-day period of benefits once both the patient’s doctor and hospice doctor certify that hospice care is fitting. After that, the hospice doctor is responsible for recertifying the patient, who may elect an additional 90 days of care, followed by an unlimited number of 60-day periods.
For more information about eligibility, use the Medicare Eligibility and Enrollment Date Calculator.
What Is Covered
Medicare pays a fixed amount for most hospice services, including:
- Doctor services and nursing care;
- Physical therapy, occupational therapy, and speech-language pathology services;
- Medical social services, hospice aide services, and homemaker services;
- Medical equipment, such as wheelchairs and walkers, and medical supplies, such as bandages and catheters;
- Drugs for symptom control or pain relief; a copayment is sometimes required;
- Counseling, including dietary counseling, counseling about care of the terminally ill patient, bereavement counseling; and
- Short-term inpatient care for pain control and symptom management and for respite, with a 5% co-pay amount.
If a hospice’s charges are more than Medicare will pay, the patient may be responsible for paying the rest. Before care begins, the hospice must tell the patient how much of the bill Medicare will pay. The agency must inform the patient, in writing, of any items or services that are not covered by Medicare and how much will be due for them. The hospice then sends bills directly to Medicare.
An individual may be charged for:
- Treatments or services designed to cure a terminal illness or not related to comfort care;
- Room and board if the patient is receiving hospice in a facility — except for temporary respite care; and
- Care in an emergency room or inpatient facility and ambulance transportation — unless arranged by the hospice provider or unrelated to the terminal illness.
For more information, see the Centers for Medicare & Medicaid Services booklet, “Medicare Hospice Benefits.”
How to Apply
Those who already receive Social Security benefits are automatically enrolled in Medicare Part A and Part B the month they turn 65.
Those who wish to apply for both Social Security benefits and Medicare can apply online — as long as they are at least 61 years and 8 months old, and want to start benefits within the next four months.
Those who wish to apply for Medicare alone must call the Social Security Administration at 800-772-1213 or 800-325-0778 (TTY) or contact the local Social Security office.
Other Medicare-Approved Plans
A number of additional plans, approved by Medicare but run by private companies, now also offer coverage for hospice services. For example, Medicare Advantage Plans generally provide Part A and B coverage, but charge different amounts for certain services — and may offer extra coverage for an extra cost. Other plans, including Medicare Cost Plans and Demonstration or Pilot Programs provide coverage for Parts A and B, with some also covering prescription drug costs.
While Medicare-approved plans increase the number of coverage options available to consumers, there are still confusing kinks in their timing, coverage, and cost. For specific questions, contact the main Medicare office at 800-633-4227 or 877-486-2048 (TTY).
For more information on Medicare coverage of hospice care, visit the Medicare Web site.
For more information on Medicare coverage and its costs, including free individual counseling, contact the local office of the Health Insurance Counseling & Advocacy Program (HICAP).
Another source of free information about hospice services, including Medicare coverage, is the California Hospice Foundation.
Medigap Coverage Medigap insurance, or Medicare supplemental insurance, is designed to cover the “gaps” between what Medicare does and does not pay. In California, 12 standard Medigap plans sold by private insurance companies are available. These plans are regulated by state and federal law and must be clearly designated as Medicare supplements, identified by the letters A through J. For home hospice care, the most common gap needing coverage is aide services – provided on more than a part-time or intermittent basis, or when there is no skilled care component. Of particular importance to those considering hospice care are Plans K and L, which generally cover hospice care co-insurance and copayments.
For more information and guidance on buying Medigap policies and an explanation of rights under them, see "Choosing a Medigap Policy — A Guide to Health Insurance for People with Medicare" (PDF).
Dual Coverage with Medi-Cal
Some people who qualify for Medicare benefits and have low income and assets levels may also qualify for full Medi-Cal coverage. For such people, known as "dual eligibles" or "Medi-Medis," Medicare will first pay for the benefits it covers-and Medi-Cal will provide secondary coverage. Also for those with dual eligibility, Medi-Cal may cover deductibles and copayments for Medicare Part A and pay for Part B premiums.
