What is Palliative Care

Palliative care is a form of holistic comfort care for patients in any stage of serious illness that is provided by a team of health care professionals in order to improve quality of life for the patient and their family members. Palliative care differs from Hospice in that it can be done in conjunction with curative treatment and it does not necessarily mean end-of-life care. 

Related: What is Palliative Care?

Medicare Coverage for Palliative Care 

Medicare is federally funded health insurance with many intricate details. Often, there are blurred lines when it comes to defining palliative care and hospice end-of-life care within the Medicare realm. 

Related: Hospice vs Palliative Care

Palliative care costs can be difficult to outline due to the fact that palliative care is personalized to the specific needs of a patient. Further, specific costs of Medicare coverage can vary for many reasons including location, type of Medicare plans enrolled in and other factors such as coinsurance. 

Connecting with Medicare personnel and discussing palliative care with referring palliative care specialists directly can help answer specific questions about coverage. Visit the Medicare Handbook 2022 for an overview of Medicare or connect with a live chat representative. See if a palliative care diagnostic test or service is covered with Medicare here

Medicare coverage for palliative care can be broken down into four parts: 

Part A  (Hospital Insurance) 

  • Hospital stays or inpatient care  
  • Short-term skilled nursing facility stays
  • Hospice care (most common form of palliative care coverage under Medicare) 
  • Limited at-home care including: skilled nursing, home healthcare and rehabilitation

Part B (Medical Insurance) 

  • Diagnostic visits from physicians and palliative treatment 
  • Medical equipment 
  • Counseling and emotional support
  • Social workers and therapists
  • Outpatient therapy for rehabilitation

Part C (Medical Advantage) 

  • Bonus coverage for medication and long-term care 
  • Special Needs Plans with flexibility and options for palliative care

Part D

  • Prescription drugs from a palliative care plan for pain management 

Out-of-pocket costs for hospital, medical care and prescription drugs may still exist for the patient. Charities, state-run programs and Medicaid may also provide additional financial and emotional support. Care coverage costs vary greatly based on personal needs and situation. To review current costs, see Medicare Costs for each plan part premiums, deductibles, copayments and coinsurance breakdowns.

Who is Eligible to Have Medicare Cover Palliative Care

Medicare is available to U.S. citizens and five year plus residents 65 and older; however, some individuals may be eligible including those receiving Social Security disability insurance. Some individuals may be a Medicare beneficiary based on a certain disability such as Lou Gehrig’s disease (ALS) among other qualifying conditions. It is important to speak to a physician for a palliative care specialist referral as well as a Medicare expert regarding eligibility and coverage.  

Related: When Should Someone Be Offered Palliative Care

In some instances (such as to qualify for Part A medicare coverage of palliative care), Medicare only provides hospice benefits so people must terminal illness to qualify for end of life palliative care services

Medicare Part A: Palliative Care

Medicare Part A is hospital insurance. It covers hospital inpatient care, skilled nursing facility care, nursing home care, hospice care and home health care. Part A is often premium-free for 65 and older; however, there are exceptions that do require a premium of $274 or $499 a month for 2022 depending on employment history and how long Medicare taxes were paid into. 

If purchasing Part A, one must have Medicare Part B and pay monthly premiums for both. Coverage may vary based on federal and state laws as well as other factors so consult a Medicare professional for specific coverage and costs.3 

Medicare Part A typically covers palliative care under hospice or end of life care where the patient has been diagnosed with a terminal illness and there is a six month or less life expectancy. 

Related: How Much Does Palliative Care Cost

Medicare Part B: Palliative Care

Medicare Part B is medical insurance. It covers medically necessary services and supplies as well as preventative care. Medicare coverage may mean paying nothing if providers are in network with Medicare, keeping in mind deductible and coinsurance. 

According to Healthcare.com1, Medicare Part B premium for 2022 is $170.10 per month. If there are social security benefits in place, premiums are taken out of that. There are also considerations for income reporting and adjustments.4 

Palliative care typically covered under Medicare Part B may include: doctor visits, lab tests (X-rays, blood tests, etc), second opinions, specialists, same-day surgeries and medical supplies, preventative care (screenings, vaccines), some prescriptions, mental health services, medical equipment, ambulance services and clinical studies that are medically relevant. 

Speak to a doctor or health care provider about Medicare coverage and if Medicare covers a specific item, service or supply. Just like with Part A, Part B coverage is based on: federal and state laws, Medicare’s decisions on whether something is covered on a national level, and local companies’ decisions that process claims based on whether something is medically necessary or covered.2

Related: Does Medicare Cover Home Health Care

Medicare Part C (Medicare Advantage): Palliative Care

Medicare Part C is also known as an MA plan or a Medical Advantage plan. It is a supplemental health plan in addition to Part A and Part B provided through private insurance companies which are approved by Medicare. 

These plans can offer more coverage and benefits. Sometimes, these optional benefit packages are not available through Medicare. Examples of extra benefits include: vision, dental and hearing, car rides to medical appointments, home-delivered meals, non-opioid pain management and health wellness programs which may be necessary for palliative care treatment. What an individual will pay depends on the plan chosen as well as the subsequent plans’ rules like seeing in-network providers. 

Examples of palliative care include the original Medicare coverage of Part A and Part B. Examples of extra benefits which may assist in palliative care include: vision, dental and hearing, car rides to medical appointments, home-delivered meals, non-opioid pain management and health wellness programs. 

Medicare Part D: Palliative Care

Medicare Part D covers prescription drugs. This may overlap into medications needed during palliative care. Medicare has multiple drug plans that have a list of what prescription drugs are covered. There are different tiers of drugs in each plan depending on price which affects the co-pay. 

For example, most generic drugs are tier one and cost the least. Costs for drug coverage depend on each plan’s premiums, deductible, copayments or coinsurance, costs in coverage gap, costs for extra help and late enrollment fees. 

Actual drug costs depend on prescriptions aligning with a plan’s covered drugs list, drug tier, benefit phase (meeting a deductible), pharmacy use, or if supplemental help is covering Medicare drug coverage.3 

Other Rules For Medicare Palliative Coverage: Medigap VS Medicare Advantage

Medigap and Medicare Advantage are supplemental plans to the original Medicare plans (Part A and Part B). However, they are quite different and beneficiaries can only choose one or the other. Medigap, or Medicare Supplement Insurance, consists of 10 types of plans that private insurance companies sell. 

Each plan has a unique blend of things covered and work to fill in the gaps of original medicare plans costs, such as out-of-pocket costs. Medicare Advantage, also a private plan sold through insurance companies, covers what Medicare Part A and B do along with supplemental coverage. 

Some plans include coverage for prescription drugs and are called Medicare Advantage Prescription Drug plans (MA-PD). These plans can vary depending on location. The main difference between the two is that Medigap is used in conjunction with original Medicare and Medicare Advantage is a replacement plan. Other differences include usage of plans, variety of plan availability and coverage differences (such as whether prescription drugs are covered).47  

Medicare Palliative Care FAQs

How long does Medicare pay for palliative care? 

Medicare pays for aspects of palliative care as long as the copayments and premiums are paid and plan enrollment is active. How much each portion or element of palliative care is paid for depends upon many factors (such as types of plans a patient is enrolled in).   

Does Medicare cover palliative care for dementia? 

Medicare does not pay for long-term care or custodial care (assistance with daily life such as eating). However, it may pay for palliative aspects of dementia care such as prescription drugs (Part D). Medicare plans may help tailor to specific dementia needs such as the special needs plans under Medical Advantage plans (Part C).  

Read more: Palliative Care for Dementia

Do Medicare Advantage plans cover palliative care? 

According to the Center of Advanced Palliative Care,5 Medicare Advantage plans are now better able to customize personal palliative care for patients. These plans may become more flexible in order to match up with personal needs as well as increase covered services such as: food, transportation, personal care aides and home-based palliative care. These changes directly impact beneficiaries of Medicare Advantage plan holders. 

Is palliative care free? 

In certain circumstances, palliative care can be free for patients; however, coverage and care varies widely based on the individual needs and plans of the patient. 

Who covers the cost of palliative care? 

Palliative care is, in many cases, covered by Medicare, Medicaid, private insurance, charity organizations or self.  

Resources

  1. What are the 5 stages of palliative care?
  2. Healthcare.com “What is Medicare Part B?” 20 December 2021. https://www.healthcare.com/what-is-medicare-part-b-160452. 6 January 2022. 
  3. Medicare.gov “What Part B Covers” https://www.medicare.gov/what-medicare-covers/what-part-b-covers. 6 January 2022. 
  4. Medicare.gov “Costs for Medicare Drug Coverage” https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage. 7 January 2022.
  5. Help Advisor “Medigap vs. Medicare Advantage” 24 November 2021. https://www.helpadvisor.com/medicare/medigap-vs-medicare-advantage. 10 Janauary 2021. 
  6. CAPC “Change is Coming to a Medicare Advantage Plan Near You” 22 April 2021, https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-june-2018-change-is-coming-to-a-medicare-advantage-plan-near-you/. 8 January 2022.
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