Palliative care is specialized medical care provided to people living with a serious illness, focusing on relief from symptoms and the stress of the condition. This care aims to improve the quality of life for both the patient and their family, addressing physical, emotional, and spiritual needs. Medicare covers many services that constitute palliative care, though the specifics vary depending on the plan and the setting of care.
Defining Palliative Care and Distinguishing it from Hospice
Palliative care is a specialized medical approach provided from the moment of diagnosis, regardless of the patient’s prognosis or illness stage. It works alongside treatments intended to cure or prolong life, such as chemotherapy. The goal is to manage symptoms of the serious illness, including pain, nausea, and difficulty breathing, while also addressing the emotional and social impact of the condition.
Palliative care differs significantly from hospice care, which is a specific Medicare benefit that includes palliative services. Hospice is reserved for individuals certified by a physician as having a terminal illness with a life expectancy of six months or less. Choosing the Medicare Hospice Benefit typically requires the patient to forgo curative treatments for the terminal illness, focusing solely on comfort and symptom management. While all hospice care is palliative, a person can receive palliative services for years while still pursuing aggressive treatment.
How Medicare Parts Cover Palliative Services
Medicare covers palliative care services through its standard benefit structure, treating them like any other medically necessary care for a serious illness.
Medicare Part B (Medical Insurance)
Part B is the primary source of coverage for most outpatient palliative services. This includes visits to palliative care physicians and nurse practitioners for symptom management, consultations, and certain therapeutic services. Part B covers these services whether they are received in a doctor’s office, an outpatient clinic, or in the patient’s home.
Medicare Part A (Hospital Insurance)
Part A covers palliative services received in an inpatient setting. This includes palliative consultations, pain management, and symptom control provided during a covered stay in a hospital or a skilled nursing facility (SNF). If an individual meets the criteria for the separate Medicare Hospice Benefit, all associated palliative services are covered under Part A with minimal out-of-pocket cost.
Medicare Part C (Medicare Advantage)
Part C offers an alternative way to receive Original Medicare (Parts A and B) benefits through a private insurance company. These plans must cover all the same medically necessary palliative services as Original Medicare. However, specific coverage rules, such as network requirements for specialists and the amount of copayments or deductibles, vary depending on the individual Part C plan chosen.
Covered Palliative Services and Patient Costs
Medicare covers services considered reasonable and necessary for managing a serious illness and its symptoms.
Covered Services Under Part B
Under Part B, covered services include physician and nurse practitioner visits focused on pain and symptom control, such as managing medications. Diagnostic tests, like X-rays or lab work, are also covered if needed to manage the illness or its related symptoms.
Outpatient therapeutic services are also covered, including physical therapy, occupational therapy, and speech-language pathology, especially when needed to maintain function or manage symptoms. Mental health support, such as counseling and psychiatrist visits, is covered under Part B to address emotional distress. Durable medical equipment (DME), such as wheelchairs or oxygen equipment, is also covered under Part B, subject to specific criteria.
Patient Costs (Outside Hospice)
When a patient receives palliative care under Original Medicare (Parts A and B) outside of the hospice benefit, they are responsible for standard cost-sharing amounts. For Part B services, the patient must first meet the annual deductible. After the deductible is met, the patient is responsible for 20% of the Medicare-approved amount for most doctor services and outpatient therapies. Prescription medications for symptom control are generally covered under a separate Part D prescription drug plan, which involves its own premiums, deductibles, and copayments.
Exclusions
Medicare does not cover services considered custodial care, such as help with bathing or dressing, when that is the only care required. Services not deemed medically necessary, such as experimental treatments or non-medical support, are also excluded from standard coverage. Room and board in a long-term care facility or at home are not covered by the standard palliative care benefit, though they are covered if the patient elects the Medicare Hospice Benefit.