Hospice Benefits

The Hospice benefit is an optional state plan service that includes an array of services furnished to terminally ill individuals.  These services include: nursing, medical social services, physician services, counseling services to the terminally ill individual and the family members or others caring for the individual at home, short-term inpatient care, medical appliances and supplies, home health aide and homemaker services, physical therapy, occupational therapy and speech-language pathology services.

Individuals must elect the hospice benefit by filing an election statement with a particular hospice.  They must acknowledge that they understand that other Medicaid services for the cure or treatment of the terminal condition are waived.   Individuals may, however, revoke the election of hospice at any time and resume receipt of the Medicaid-covered benefits waived when hospice was elected.

A hospice provider must obtain a physician certification that an individual is terminally ill and hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions.  A hospice plan of care must be established before services are provided.

There are four levels of hospice care: 1) routine home care where most hospice care is provided; 2) continuous home care which is furnished during a period of crisis and primarily consists of nursing care; 3) inpatient respite care which is short-term care and intended to relieve family members or others caring for the individual; and 4) general inpatient care which is short term and intended for pain control or acute or chronic symptom management which cannot be provided in other settings.

Many commercial or private insurance companies, such as Anthem, Aetna, Cigna, Blue Cross/Blue Shield, and others, include hospice care benefits as part of their health insurance policies. The number of visits, types of services and requirements for coverage vary greatly. It is therefore necessary to check each commercial insurance policy for the particular patient and situation.

In general, many commercial insurance policies require a prior hospital stay, physician’s orders and need for intermittent skilled services to cover the cost of Hospice Care Services. Commercial insurance companies are increasingly offering case management programs that provide a variety of community-based services, including Hospice Care Services, as an alternative to more expensive institutional care.

Probably the least frequent payment source for hospice care is self-pay in which hospice agency reimbursement is made by the patient, family members, or other source of private income. This source is obviously the least restrictive in terms of eligibility requirements, since it is basically a contract between a client/family and the agency.

An agency’s own admission requirements will dictate the eligibility requirements and will probably include physician’s orders at a minimum.

Many states have established special funding sources for hospice care. Please contact Reliance for your healthcare needs.