Does insurance cover hospice care?

Most insurance plans cover hospice care, but it is a good idea to confirm your own coverage before you begin.

If you decide to try a new treatment or go into hospice, contact your health insurance company. Most plans cover hospice, and they may also cover brief home visits from a nurse or a home health aide several times a week. However, coverage can vary, so it is wise to ask in advance.

Medicare sets the pattern that most other plans follow, so it is worth knowing in detail. Under Medicare, you pay nothing for hospice care itself when you use a Medicare-approved hospice provider. Two small charges remain. You may pay up to $5 for each outpatient prescription for symptom relief, and 5% of the Medicare-approved amount for inpatient respite care.

Getting that coverage requires two steps. Your hospice doctor and your regular doctor certify that you are terminally ill, with a life expectancy of 6 months or less. You then sign a statement choosing comfort care instead of treatment aimed at curing the illness. Medicare-approved hospice care can usually be delivered in your home, or in another place where you live, such as an assisted living facility or a nursing home.

Now the part that surprises families most. The hospice benefit does not pay room and board. If your loved one lives in a nursing home or assisted living, hospice covers the nurses, medicines, equipment, and visits, while the monthly cost of the room stays exactly where it was. Nothing about signing up for hospice reduces that bill. Ask about it directly before you enroll, because assuming otherwise can wreck a family budget in a month.

Two other exclusions matter. Treatment intended to cure the illness is not covered under the hospice benefit, and neither are some drugs unrelated to the terminal condition. If you are taking medicines for other long-standing conditions, ask the hospice specifically which ones they will supply and which ones you keep filling as before.

Checking your coverage early may prevent payment problems later. If you need help understanding your benefits or with financial matters, you do not have to sort it out alone. A hospital social worker or financial counselor can help, and your health care team can point you to resources for questions about paying for care.

Five questions get you a clear picture in one phone call. Is this hospice approved by my plan? What will I owe out of pocket each month? Does the benefit cover room and board where I live now? Which of my current medicines will hospice provide? And what happens if I change my mind and want to return to active treatment?

That last question has a reassuring answer more often than people expect. Choosing hospice is not a one-way door, and people do leave hospice and return to it later.