Medicare, Medi-Cal, and Private Insurance
Hospice care is a fully covered benefit under Medicare Part A and the Medi-Cal program in California. Most insurance companies also provide coverage for hospice care subject to individual policy deductibles, coinsurance, and out-of-pocket limitations.
When a patient is considering hospice care, the insurance coverage of the patient will be reviewed and discussed with family members to be sure they understand the financial benefits provided to the patient by their current insurance carrier. If there are any questions, they will be resolved prior to the start of care.
For an individual eligible and enrolled in Medicare or Medi-Cal, there is no out-of-pocket cost to select the hospice benefit. The hospice benefit includes full payment for all staff services, supplies, medical equipment, and medications, provided they are directly related to the hospice primary diagnosis.
To qualify for hospice care, two physicians, generally the patient's attending physician and the hospice physician, evaluate the patient to determine if the individual has a life-limiting illness with a life expectancy of six months or less if the disease process follows a normal course.
Because it is impossible to know the progression of a disease with accuracy, patients may receive the hospice benefit for longer than six months provided they continue to meet the Medicare or insurance company eligibility criteria. After six months, patients are periodically assessed by hospice physicians for continued coverage.
When an individual elects the hospice benefit for a specific disease diagnosis, they are opting out of traditional Medicare coverage and opting into the special Medicare hospice benefit. By doing this, they agree to pursue comfort and palliative measures only and not seek aggressive or curative therapy for that disease. Should other diseases develop, unrelated to the hospice diagnosis, those may be treated and covered under the traditional Medicare program.
When all requirements are met, the following services will be covered by your health plan:
- Physician services
- Nursing care
- Home health aide
- Medical social services
- Bereavement counseling
- Spiritual counseling
- Dietary counseling
- Volunteer services
- Physical therapy, occupational therapy, speech therapy
- Medical equipment, services, and supplies
- Medications for pain and comfort related to the terminal illness and approved by Skirball Hospice
- Short-term inpatient care for pain and symptom control
- Diagnostic studies
- Short-term continuous care for focused symptom relief
- Respite for up to 5 days to provide relief for caregivers
The following services are not covered:
- Treatment for the terminal illness which is not for palliative symptom management and is not within the hospice plan of care
- Care provided by another hospice or home health agency
- Private caregivers/sitter services
- Dietary supplements unless directly related to terminal illness
- Services not authorized by Skirball Hospice
- Ambulance transportation not included in the plan of care
- Supplies not related to terminal illness
- Chemotherapy drugs or other drugs deemed aggressive in nature
- Medications not related to the terminal illness
- Visit to the emergency department or inpatient hospitalization without prior authorization from Skirball Hospice
- Diagnostic studies or any treatments not authorized by Skirball Hospice