Does insurance cover palliative care?

Usually, yes. The National Cancer Institute says private health insurance usually covers palliative care services. Medicare and Medicaid also pay for some kinds. NCI's example is Medicare Part B, which pays for some medical services that address symptom control. Medicaid rules vary by state, so what is covered depends on where a person lives.

Why the billing is simpler than it sounds

Palliative care is not a separate product to sign up for. It is medical care, delivered by clinicians, and it is billed the way other medical care is billed.

A palliative care visit is a doctor or nurse visit. A consult in the hospital is a specialist consult. Medicine for pain or nausea runs through drug coverage. So most of it flows through benefits that already exist, under the plan's usual deductible and coinsurance.

NCI says this care can be given in a hospital, an outpatient clinic, a long-term care facility, or at home. The team may include doctors, nurses, dietitians, pharmacists, occupational and physical therapists, chaplains, psychologists, and social workers.

Hospice is paid for under different rules entirely

This is where the two get confused, and the money works differently.

Hospice is a Medicare Part A benefit. Medicare covers two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods.

Getting in has specific requirements. Medicare asks for a life expectancy of 6 months or less. After 6 months, hospice care can continue. The hospice medical director or hospice doctor must recertify that the person is still terminally ill. That follows a face-to-face meeting with a hospice doctor or nurse practitioner.

There is also a right worth knowing: a person can change hospice provider once during each benefit period.

What Medicare hospice actually costs

Medicare says a patient pays nothing for hospice care from a Medicare-approved provider. Two exceptions are worth knowing in advance.

• A copayment of up to $5 for each prescription for outpatient drugs for pain and symptom control.
• Up to 5% of the Medicare-approved amount for inpatient respite care, which gives a caregiver a rest. That copayment cannot be more than the inpatient deductible.

Room and board is the surprise. Medicare does not cover it for hospice at home, in a nursing home, or in a hospice inpatient facility. But if the hospice team decides short-term inpatient or respite care is needed and arranges it, Medicare covers that stay.

Three other things fall outside the benefit once hospice starts. Treatment meant to cure the terminal illness. Care from any hospice provider the hospice team did not set up. And hospital or ambulance care the team did not arrange, unless it is unrelated to the terminal illness.

That last one comes with an instruction. Medicare says to contact the hospice team before getting such services, or the full cost may fall to the patient. A hospice provider can also be asked for a written list of items, services, and drugs it has judged unrelated to the terminal illness, with the reasons.

Two calls that get real answers

Call the number on the insurance card and ask two specific questions. Is a palliative care consult covered under this plan? And is there an in-network palliative care team nearby? A vague question about "palliative care" tends to get a vague answer. A question about a specialist consult usually does not.

If a team suggests palliative care and cost is the worry, ask how the visit will be billed and what the patient share would be.

NCI adds a fallback for anyone without insurance, or unsure of their coverage. Check with a social worker or the hospital's financial counselor. Our guide to palliative care covers what it includes, and medicare and cancer covers the wider benefit.

NCI's palliative care fact sheet was last reviewed on November 1, 2021.

Sources

• https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
• https://www.medicare.gov/coverage/hospice-care