Article at a glance
Palliative care is a type of specialized medical service most often for those with life-threatening or serious illnesses, such as congestive heart failure, cancer, dementia, kidney disease, chronic obstructive pulmonary disease (COPD), and others. Palliative care is for anyone who needs to improve their quality of life and reduce suffering.
Palliative care brings comfort to the patient, improving their quality of life during the course of illness. Palliative care benefits the quality of life for the patient’s family members as well.
Palliative care and hospice care are often used interchangeably, but these are not the same medical service. Hospice care is a type of palliative care that is provided at end of life only. Palliative care, on the other hand, is for those at any stage of illness, regardless of prognosis. It is not dependent on life expectancy.
What Medicare covers in regards to palliative care will depend on a variety of factors. Some such factors include whether the patient has Original Medicare or Medicare Advantage, as well as any other medical insurance they may have. The type of palliative care will also play a role.
Discussing coverage with a licensed insurance agent can help bring clarity to a patient’s medical insurance, helping them to make the most informed decision possible.
Knowing what Medicare covers, in the event of being diagnosed with life-limiting or serious illness, can make responding to the matter far easier. Someone with a serious or life-limiting illness may be interested in receiving palliative care, a specialized service focused on improving the patient’s quality of life through pain and symptom management.
Many Medicare beneficiaries may need palliative care during their lifetime, especially if diagnosed with a life-limiting illness. However, does Medicare cover palliative care? Whether palliative care is covered by Medicare will be based on a number of factors, as some Medicare plans do and some Medicare plans only cover palliative care in certain scenarios (i.e. when it is hospice care).
Understanding exactly what palliative care is and associated services will make understanding what is covered by Medicare far easier to navigate for the patient. Read on to uncover how Medicare covers palliative care and more.
Understanding Palliative Care
Palliative care’s main goals are pain and symptom management, as well as enhancing the patient’s current care as a means of improving their overall quality of life. Palliative care is usually provided at the patient’s home. This can include a skilled nursing facility if that is where the patient resides.
Palliative care, also known as comfort care, is a type of specialized medical service for those with a severe or life-limiting illness. Palliative care is for anyone with a serious illness, no matter their age, disease stage, prognosis, or treatment choice. Palliative care can last for months, weeks, or even years.
Palliative care is an interdisciplinary approach. The palliative care team is made up of a team of various professionals that can address all facets of the patient’s wellness, including, but not limited to, the patient’s physical, mental, emotional, social, and financial health.
Palliative Care Benefits
According to Harvard Health, there are a number of benefits associated with palliative care services. Some such benefits of palliative care include improved quality of life, added comfort, and enhanced resilience. Other research has shown palliative care can raise the patient’s life expectancy due to their improved quality of life.
Palliative care can help patients with pain and symptom management. In addition to pain relief, this can include addressing other troublesome physical symptoms such as shortness of breath. Palliative care may also address mental and emotional symptoms such as insomnia, depression, anxiety, and fatigue. Palliative care can also provide spiritual support as needed.
Palliative care also helps patients navigate their medical treatment options. The palliative care team will spend time talking with the patient to understand their goals for palliative care, coordinating with the patient’s doctors to match those goals to treatment.
Palliative Care and Treatment
Palliative care is available in addition to life-prolonging and/or curative treatments such as chemotherapy. A patient does not have to choose between treatment and palliative care. In fact, palliative care is meant to bolster the patient’s treatment, providing added comfort during the course of their serious illness, whatever the illness may be.
Who makes up the palliative care team?
After getting diagnosed with a serious illness, a patient’s regular doctor can refer them to a palliative care specialist. The patient can also ask for a referral if the doctor does not bring up palliative care as an option.
Once contacted, the palliative care specialist will work to create the patient’s palliative care team. This specially trained team can be comprised of a variety of health care providers such as:
Palliative care doctor
Palliative care nurse
Palliative care specialist
Since palliative care teams are tailored to a patient’s specific needs, no two palliative care teams will look the same. For example, someone with cancer will have their palliative care provider coordinate with their oncologist for pain relief, while a patient experiencing congestive heart failure will need to have a cardiologist on their team to manage physical symptoms associated with their heart condition.
In ideal situations, palliative care begins early on in the patient’s treatment, continuing throughout the course of their illness. In fact, many patients are referred to palliative care too late.
One study showed that those who began palliative care early on in treatment for metastatic non-small-cell lung cancer experienced “significant improvements in both quality of life and mood.” In addition, that same study saw the group that received early palliative care early had less aggressive end-of-life care than the group that only received standard care.
Palliative Care vs. Hospice Care: What’s the Difference?
Hospice and palliative care are not the same health care service. While one of the main goals of both hospice and palliative care is to bring comfort to the patient, these services are different in regards to when each would be needed.
Palliative care is not dependent on prognosis or life expectancy, while hospice care is available at the end of life only. Hospice care is for those who are considered terminally ill and are no longer responding to treatments or choose not to pursue curative treatment. End of life is defined in this scenario as a life expectancy of six months or less left to live.
Common Conditions Palliative Care Helps
There are a number of conditions that may benefit from palliative care. Some such serious illnesses include:
Amyotrophic lateral sclerosis (ALS)
Chronic obstructive pulmonary disease (COPD)
End-stage liver disease
Multiple sclerosis (MS)
Congestive heart failure
Does Medicare Cover Palliative Care?
Medicare will cover palliative care like it covers any other specialty care depending on a patient’s plan and when medically necessary.
The federal Medicare program is comprised of Original Medicare and the Medicare Advantage Plan. Whether palliative care is covered by Medicare will be dependent on the patient’s individual plan and selected benefits.
Typically, under Medicare, hospice care is covered. However, if a patient is receiving palliative care that is not designated as hospice care, the patient will have to pay standard out-of-pocket expenses. Such costs can include premiums, deductibles, copayments, and coinsurance. For Medicare beneficiaries under a Medicare Advantage plan, additional premiums, deductibles, copayments, and coinsurance costs may be possible.
Original Medicare is comprised of Part A and Part B. Medicare Advantage plans are referred to as Medicare Part C, typically covering what is covered under Original Medicare with added benefits. Medicare Part D refers to prescription drug coverage. Each plan will vary in regards to how each one will cover palliative care.
Medicare Part A is hospital insurance. Hospital insurance is essentially any service required in an inpatient setting.
In most cases, Part A covers:
Inpatient hospital stays
Skilled nursing facility care
Nursing home care
Under hospital insurance, hospice services are fully covered by Medicare. While hospice care is a type of palliative care, not all palliative care is hospice care. Again, hospice care is only given at end of life and Medicare requires a doctor to verify this is the case for the patient. Basic palliative care is for anyone, no matter their prognosis or disease state. In the event a patient is not terminally ill, Medicare Part A may not cover palliative care if it is not classified as hospice care.
Medicare Part B is medical insurance, referring to outpatient services.
Covered services under Part B include:
Durable medical equipment
Mental health counseling
Outpatient rehabilitation therapy (occupational therapy, physical therapy, and speech therapy)
If a patient is not in hospice but still wants to receive palliative care, Part B can help cover palliative care services not covered under Part A. However, again, premiums and other out-of-pocket costs should be accounted for as the patient, in this case, would have to pay for palliative care.
Medicare Part C is known as the Medicare Advantage Plan which helps to bundle Medicare coverage into an all-encompassing package. This Medicare plan is sold by private insurance companies that contract through Medicare. If someone is enrolled in a Medicare Advantage plan, many Medicare Advantage plans will cover the same services as Medicare Part A and Medicare Part B. This includes the palliative care services under those Parts.
Medicare Advantage plans will vary in coverage, however, and may offer additional services such as long-term care. Medicare Advantage plans include the following:
Health Maintenance Organizations
Preferred Provider Organizations
Private Fee-for-Service Plans
Special Needs Plans
Medicare Medical Savings Account Plans
Many Medicare Advantage plans cover prescription drugs.
Medicare Part D is prescription drug coverage. Some medications used for palliative care may be covered under Part D. The World Health Organization states that medications are typically prescribed for anorexia, depression, anxiety, diarrhea, nausea, and other conditions during palliative care.
Medicare and Hospice Care
Hospice care is a type of palliative care reserved for the end of life. It is difficult for doctors to predict the timeline for end of life. However, in order to cover hospice care, Medicare requires someone’s health care provider or a hospice doctor to certify the patient is at end of life, meaning they have a terminal illness. If that’s the case, Original Medicare will cover hospice care. Most Medicare Advantage plans, as aforementioned, will cover hospice care since it falls under Part A.
If six months pass, the patient can continue receiving hospice care so long as the hospice doctor re-certifies the patient is still terminally ill during a face-to-face meeting.
In the event a patient is confirmed by a health care provider as being terminally ill, the patient then must sign a statement choosing hospice care as opposed to other benefits Original Medicare covers to treat their terminal illness and other related medical issues.
This includes the following services:
Anything necessary for pain and symptom management
Medical, nursing, and social services
Prescription drugs for managing pain
Durable medical equipment for pain relief and symptom management
Aide and homemaker services
Speech-language pathology services
Grief counseling and spiritual support for the patient and family members
Inpatient respite care
In regards to inpatient respite care, this will need to be at a Medicare-approved facility. Respite care is important because it gives the patient’s caregiver can take time to rest. The hospice provider arranges this service for the patient. Respite care will be covered in five-day increments at a time, and it can be used more than once, but only on an occasional basis.
Again, if a patient has a Medicare Advantage plan, the same aforementioned services are also most likely covered.
There are a number of hospice services that Medicare will not cover. Medicare will not cover the following services once a patient’s hospice benefit begins:
Curative treatment intended to cure terminal illness and related conditions: Patients who elect for hospice care can choose to stop at any time. A hospice patient should talk to their doctor if they are considering curative treatment.
Prescription drugs intended to cure the illness: This does not include symptom control or pain relief.
Care from any hospice provider that was not set up and approved by the hospice medical team: Hospice care must be administered by the hospice provider chosen from the start. All care received for the patient’s terminal illness must be given and/or arranged by the hospice team. A patient cannot receive care from a different hospice. However, a patient is able to see their primary care doctor or nurse practitioner if they have chosen either to be the attending medical professional that supervises their hospice care.
Room and board: This includes care received in the patient’s home, a nursing home, or a hospice inpatient facility. However, if the hospice team decides that patients need short-term inpatient care or respite care services they can arrange, Medicare will cover the patient to stay in the inpatient facility. (Patients may have to pay a copayment for the respite stay).
Inpatient care, outpatient care, and ambulance transport not arranged by the hospice team: As well, these services must be unrelated to the patient’s terminal illness and related conditions.
Medicare Costs for Hospice Care
Patients should always consult their hospice team before receiving any services. Otherwise, they risk paying the entire cost. However, Original Medicare costs for hospice care are fairly straightforward. According to the official Medicare website:
Patients pay nothing for hospice care under Original Medicare. This is under Medicare Part A.
A copayment of up to $5 for outpatient prescription drugs. This includes prescription drugs for pain and symptom management. However, if there is a rare case in which the hospice benefit does not cover the patient’s prescription drug, the hospice provider can contact their Medicare plan to investigate whether Medicare Part D covers it.
A hospice patient may pay 5% of the Medicare-approved amount for inpatient respite care. For patients with Original Medicare, the Medicare-approved Amount refers to a set price a doctor or supplier that accepts the assignment can be paid. This price may be less than the actual amount a doctor or supplier charges. If that’s the case, Medicare will pay part of that amount and the patient will be responsible for the difference.
Medicare still recommends that a patient discuss their options with a health care provider first, since the amount owed may vary based on factors such as where a test, item, or service is provided.
If a patient had a Medicare Advantage plan prior to starting hospice care, the patient can choose to stay on that health plan as long as the premiums and other costs continue to be paid.
Making the Most of Palliative Care
To make the most of palliative care, Medicare beneficiaries should discuss their options with a licensed insurance agent and their health care provider to understand exactly what is covered. A patient can also use this search tool on the official Medicare site to see if a particular test, item, or service is covered.
How long can a patient receive palliative care?
Palliative care can last for years and is up to a provider and patient to decide what time it’s best to begin palliative care.