Have you or a loved one been diagnosed with a life-limiting illness? If so, then hospice care and how to pay for it is no doubt top of your list of priorities. Hospice is for patients with six months or less to live. Though this life transition is stressful enough on its own, for many it also bears the question of how to pay for these services. Luckily, Medicare covers most people who enter hospice, but not all. Here we will break down who is eligible for Medicare, how much of hospice care it covers, and what options exist for those who require hospice but do not qualify.

Am I eligible for Medicare?

There are four parts to Medicare. Part A, also called Hospital Insurance, covers inpatient care, skilled nursing facility care, hospice care, and certain home health care costs. Part B, also called Medical Insurance, covers outpatient care services such as doctor’s visits, outpatient care, certain home health care costs, durable medical equipment, as well as certain preventative care services. The other two parts of Medicare, Parts C and D, are add-on insurance services that cover everything from prescription drug costs to specialty health care services.

For patients considering or eligible for hospice, the only part of Medicare that matters is Part A. Medicare Part A specifically covers hospice care. Some people are automatically eligible and enrolled in Medicare Part A. The criteria To be eligible for Part A automatically are:

1. You are already receiving social security benefits.
2. Your are disabled and have received disability benefits for over 24 months.
3. You have Amyotrophic Lateral Sclerosis (ALS) and receive social security benefits.

Anyone who does not meet these criteria must sign up for Part A. For example, people who are close to 65 – within 3 months – and not yet receiving social security benefits must apply. People with end stage renal disease who want medicare coverage must also apply, unless they meet at least one of the criteria stipulated above.

Who is not eligible for Medicare Part A?

Typically, the people who are not eligible for Medicare coverage under Part A are children and young adults with life-limiting illness. In these cases, the parents’ health insurance should cover the cost of hospice services. Young adults aged 18-35 with life-limiting illness are also not generally eligible for Medicare unless they qualify for social security benefits from the Americans with Disabilities Act (ADA). If you or your loved one are facing a life-limiting illness, qualify for hospice care, but are unsure of your Medicare eligibility, simply call 1-800-MEDICARE to speak with a representative to discuss your eligibility and options.

How much of my hospice care will Medicare Part A cover?

If you are eligible and enrolled in Medicare Part A, your hospice care is entirely covered assuming you meet the criteria set forth by medicare.gov. In their 2017 “Medicare & You” informational packet, the exact eligibility requirements for hospice care to be covered by Medicare are explained as follows.

To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. If you’re already getting hospice care, a hospice doctor or nurse practitioner will need to see you about 6 months after your hospice care started to certify that you’re still terminally ill. Coverage includes:

1. All items and services needed for pain relief and symptom management.
2. Medical, nursing, and social services.
3. Drugs.
4. Certain durable medical equipment.
5. Aide and homemaker services.
6. Other covered services, as well as services Medicare usually doesn’t cover, like spiritual and grief counseling.

A Medicare-approved hospice usually gives hospice care in your home or other facility where you live, like a nursing home.

Hospice care doesn’t pay for your stay in a facility (room and board) unless the hospice medical team determines that you need short-term inpatient stays for pain and symptom management that can’t be addressed at home. These stays must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility that contracts with the hospice. Medicare also covers inpatient respite care, which is care you get in a Medicare-approved facility so that your usual caregiver (family member or friend) can rest. You can stay up to 5 days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness or related conditions. You can continue to get hospice care as long as the hospice medical director or hospice doctor re-certifies that you’re terminally ill.

Will I have to pay anything out of pocket?

While you pay nothing for hospice care, there are costs associated with hospice that you will need to cover. There are only two financial obligations for hospice patients covered by Medicare. First, you must pay a copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Part D. You also must pay five percent of the Medicare-approved amount for inpatient respite care.

What else do I need to know about Medicare requirements for hospice patients?

Every patient is different, and every case is different. To be completely sure about your eligibility for both hospice care and Medicare, it is helpful to contact a hospice provider in your area. They can help guide you through this difficult and unnerving process. Hospice providers have a deep understanding of how the Medicare system works. They will help you to find the care you need with the coverage you deserve. To connect with a hospice provider near you, simply call 1-800-HOSPICE.