Medicare coverage of  Hospice, Palliative & respite care

What about Medi Gap, Medicare Advantage & ACA/Obamacare?

Hospice Coverage
Introduction

Hospice is a program of care and support for people who are terminally ill (with a life expectancy of 6 months or less, if the illness runs its normal course) and their families. Here are some important facts about hospice:

■ Hospice helps people who are terminally ill live comfortably.
■ Hospice isn’t only for people with cancer.
■ The focus is on comfort (palliative care), not curing an illness.
■ A specially trained team of professionals and caregivers provide care for the “whole person,” including  physical, emotional, social, and spiritual needs.
■ Services typically include physical care, counseling, drugs, equipment, and supplies for the terminal  illness and related conditions.
■ Care is generally given in the home.
■ Family caregivers can get support.

To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. When you agree to hospice care, you’re agreeing to comfort care (palliative care) instead of care to cure your illness. You also must sign a statement choosing hospice care instead of other benefits Medicare covers to treat your terminal illness and related conditions. Publication 02154

Depending on your terminal illness and related conditions, the plan of care your hospice team creates can include:

any or all of these services: 

  • Doctor services
  • Nursing care
  • Medical equipment (like wheelchairs or walkers)
  • Medical supplies (like bandages and catheters)
  • Prescription drugs for symptom control or pain relief
  • Hospice aide and homemaker services
  • Physical therapy services
  • Occupational therapy services
  • Speech-language pathology services
  • Social work services
  • Dietary counseling
  • Grief and loss counseling for you and your family
  • Short-term inpatient care (for pain and symptom management)
  • Short term respite care
  • Any other Medicare-covered services needed to manage your pain and other symptoms related to your terminal illness and related conditions, as recommended by your hospice team medicare.gov/hospice-care

When you choose hospice care, you decide you no longer want care to cure your terminal illness and/or your doctor determines that efforts to cure your illness aren’t working.

Resources & Links

NPR  Home Hospice can be tough on families 1.21.2020

Medi Gap Plan G…

hospice coverage under medi gap

plan g coverage hospice

 

Medicare Advantage

See typical Evidence of Coverage page 69 

Official Medicare #Hospice Publication  # 02154  

you tube videos

Costs of the last 2 months of life 

costs of last 12 months of life

 

See our webpage on

Trump  Make America Healthy Again

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Even more shockingly, one-quarter of our teenagers today are pre-diabetic or have type-2 diabetes, and obesity is the leading medical reason that 71 percent of young Americans are disqualified from military service.  Learn More >>> The Hill 

6 positions 

1. Mr. Kennedy has prioritized addressing chronic disease, which accounts for over $1 trillion in annual U.S. healthcare costs. He has stated that President-elect Trump seeks "measurable impacts" to combat the chronic disease epidemic within two years — a goal that has drawn attention from healthcare leaders, some of whom have praised its ambition while noting potential challenges.

Mr. Kennedy identified chronic disease as a key priority before his nomination to lead HHS. "I'm going to urge President Trump on day one to do the same thing they did in COVID, which is to declare a national emergency, but not for infectious disease, but for chronic disease," Mr. Kennedy said in a Sept. 26 interview, about one month after he dropped out of the presidential race.

His vision extends beyond healthcare delivery to address broader contributors to chronic disease. Mr. Kennedy has criticized the influence of the pharmaceutical and food industries, linking issues like obesity and diabetes to ultra-processed foods, federal subsidies and dietary guidelines. He has called for reforms targeting food additives, pesticides and environmental health risks, alongside overhauls of agencies like the CDC and FDA.

Health systems may find some common ground in Mr. Kennedy's focus on prevention and early intervention to reduce chronic disease burdens, which could align with some of their efforts to address social determinants of health. However, experts, including former CDC Director Tom Frieden, MD, caution against oversimplification. "There are some things that RFK Jr. gets right," Dr. Frieden told NPR. "We do have a chronic disease crisis in this country, but we need to avoid simplistic solutions and stick with the science."

2. He's called for an end to direct-to-consumer advertising for prescription drugs. Mr. Kennedy has criticized the advertising relationships between pharmaceutical companies and news outlets, arguing that pharmaceutical advertising influences editorial content and public discourse beyond its intended purpose of promoting products. When his campaign was active in early 2024, Mr. Kennedy said if elected he would issue an executive order on his first day in office to ban pharmaceutical advertising on television.

Direct-to-consumer advertising of prescription drugs surged after the FDA eased restrictions in 1997 and totaled nearly $10 billion in 2016. Proponents argue it educates consumers and empowers patient involvement, while critics warn it can misinform patients, drive inappropriate prescribing and inflate healthcare costs. Concerns also include promoting costly brand-name drugs over cheaper alternatives, straining patient-physician relationships.

3. He has expressed interest in redirecting Medicare spending toward promoting healthy behaviors rather than covering certain pharmaceuticals. Mr. Kennedy has been a vocal opponent of Medicare and Medicaid funding for GLP-1 drugs used for weight loss, arguing that these programs should instead prioritize covering gym memberships and healthier food options for enrollees.

"For half the price of Ozempic, we could purchase regeneratively raised, organic food for every American, three meals a day and a gym membership, for every obese American," Mr. Kennedy said during a Congressional roundtable in September, as reported by the Associated Press.

The Biden administration recently proposed broader coverage of GLP-1 and weight loss drugs for Americans with obesity, a move that could put Mr. Kennedy in a reactive position if he secures confirmation to lead HHS.

4. He is considering changes to the Medicare physician fee schedule. Mr. Kennedy and his advisers are considering an overhaul of Medicare's payment formula, four anonymous sources told The Washington Post in November. The move could mark a bid to shift the health system's incentives toward primary care and prevention.

The Medicare physician fee schedule was adopted in 1992, establishing a complex system of administrative pricing based on the resource inputs used in producing physician services. It influences not only Medicare payments, but also private insurance payment systems, which often mirror Medicare's methodologies.

Sources told The Post that discussions about the fee schedule are in their early stages and have involved a plan to review the thousands of billing codes that determine how much physicians get paid for performing procedures and services. These codes are integral to determining reimbursement rates and have faced criticism for historically favoring procedural and specialty care over primary care services. An overhaul could address these disparities and potentially reshape the economics of medical practice across the country.

5. He has raised controversial and widely challenged claims about vaccine safety for nearly 20 years. Mr. Kennedy's suspicion of vaccines dates back to at least 2005, when he published an article called "Deadly Immunity" in unusual publications for the topic: Rolling Stone magazine (print) and Salon (digital). The article claimed that thimerosal, eliminated in routine childhood vaccines in 2001, caused autism. The article was amended and corrected several times before, years later, Salon announced in 2011 that it was retracting "Deadly Immunity" in entirety. An explanation of that decision and the corrections made to Mr. Kennedy's article are detailed by Salon here.

More recently, Mr. Kennedy said in a 2023 podcast interview that, "There's no vaccine that is safe and effective." The nonprofit Mr. Kennedy was aligned with for nearly a decade, Children's Health Defense, has been a vocal critic of COVID-19 vaccines and public health mandates, with its claims frequently challenged by public health experts. The group has filed dozens of federal and state lawsuits since 2020, many challenging vaccines and public health mandates. Mr. Kennedy has been on leave from the group as its founder, chairman and chief litigation counsel since he announced his plans to run for president in April 2023.

When described as anti-vaccine, Mr. Kennedy has pushed back. Instead, he argues that he wants to improve the science of vaccine safety. "We're not going to take vaccines away from anybody," he told NPR in November. "We are going to make sure that Americans have good information. Right now the science on vaccine safety particularly has huge deficits in it, and we're going to make sure those scientific studies are done and that people can make informed choices about their vaccinations and their children's vaccinations."

6. He supports abortion rights up to the point of fetal viability, after which he favors restrictions. Mr. Kennedy believes abortion should be legal up to a point he describes as when the fetus becomes viable outside the womb, after which he supports restrictions. Mr. Kennedy clarified this position in a video released in June 2024, though he did not specify an exact number of weeks for viability. He acknowledged that his views on abortion have evolved over time as he continued to explore the issue. In May 2024, he had expressed support for a woman's right to choose an abortion at any stage of pregnancy, including full term.

Mr. Kennedy has also pointed to the importance of addressing economic factors in discussions about abortion and reproductive health. "We should be looking at why there are so many abortions in the first place," he said, emphasizing the need to understand the financial challenges and economic pressures that contribute to abortion rates among individuals and families.

Mr. Kennedy introduced a plan while running for president called "More Choices, More Life" that called for a subsidized daycare initiative aimed at making childcare more accessible. He said universal childcare has the capacity to add $1 trillion to the U.S. GDP. "And since economics is a major driver of abortion, this policy will do more to lower abortion rates than any coercive measure ever could," the website for the plan states.    Becker Hospital Review

Your Costs in Hospice

Long Term Care Coverage 

Your costs in Original Medicare

  • $0 for hospice care.
  • You may need to pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you’re at home. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Part D Rx
  • You may need to pay 5% of the Medicare-approved amount for inpatient respite care.
  • Medicare doesn’t cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).
    • If you pre planned  got Long Term Care or Home Health Care those may.

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

  • Other insurance you may have
    • Medi Gap, Medicare Advantage?
  • How much your doctor charges

Medicare won’t cover any of these once your hospice benefit starts:

  • Treatment intended to cure your terminal illness and/or related conditions. Talk with your doctor if you’re thinking about getting treatment to cure your illness. As a hospice patient, you always have the right to stop hospice care at any time.
  • Prescription drugs to cure your illness (rather than for symptom control or pain relief).
  • Care from any hospice provider that wasn’t set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.
  • Room and board. Medicare doesn’t cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
  • Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness and related conditions.  medicare.gov/hospice-care

Contact your hospice team before you get any of these services or you might have to pay the entire cost.

Hospice, Euthanasia, Links & Resources

Skilled Nursing Homes

How does Medicare pay  for #SkilledNursing Homes - 10153 11359

Our Introductory You Tube VIDEO based on this manual

video medicare skilled nursing

FAQ’s  Catheters

  • What catheters providers are in network with my plan
    • What plan do you have?Anthem Provider Finder

       

      Blue Shield Provider Finder
      https://www.blueshieldca.com/fad/home

       

      • Here’s the reply on 180 Medical about how Insurance covers catheters.180medical.comMedicare Coverage per 180 Medical 180medical.comWhat does your prescription say?

        Unlike Medicare, most Medicaid – Medi Cal? programs and most commercial insurers, UnitedHealthcare—the nation’s largest insurer—excludes urinary catheters from coverage for many commercial plans, lumping them in the same category as other excluded disposable supplies like elastic bandages and gauze. modernhealthcare.com

        Coloplast.com FAQ’s on Insurance Coverage .coloplastcare.com

      • Anthem Medi Blue Plus HMO
        • OK, let’s check the Evidence of CoverageLet’s check for participating pharmacy’s https://shop.anthem.com/medicare/ Scroll down for the tool.CVS Pharmacy on Catheter’s

          You can use ANY participating pharmacy!

          • What about the 20% Co Pay?I wasn’t paying that with 180 Medical.
            • You’re right. Since you are not in CA, I can’t really help you. Try calling the agent who you purchased the coverage from or Blue Cross in your State.excerpt of CA Summary of Benefits
            • I’m not 100% sure if a Medicare Provider is allowed to waive the 20% charge. Here’s some links. It’s beyond my pay grade…oig.hhs.gov/fraudbakerdonelson.com

              healthreformquotes.com/fraud-waste-abuse/

  • Catheter Fraud???  

Anthem Medicare Supplement

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