Hospice care is a specialized philosophy focused on providing comfort, dignity, and quality of life for individuals with a terminal illness, rather than seeking a cure. This comprehensive approach addresses medical, emotional, and spiritual needs, often delivered in the patient’s home. A primary concern for many Ohio families is understanding the financial mechanisms that cover these services. Funding for hospice is a combination of federal, state, and private programs designed to ensure accessibility.
Medicare Coverage for Hospice Services
The Medicare Hospice Benefit, covered under Medicare Part A, serves as the primary funding source for the majority of hospice patients. Eligibility requires the individual to be entitled to Medicare Part A. Two physicians—the attending doctor and the hospice medical director—must certify that the patient has a terminal illness with a prognosis of six months or less. This prognosis is not a rigid limit, as the benefit can be recertified for subsequent periods if the patient continues to meet the criteria.
Electing the Medicare Hospice Benefit requires the patient to waive Medicare payments for curative treatments related to the terminal illness. The focus shifts to palliative care, centered on pain relief and symptom management. Medicare still pays for covered benefits for health problems unrelated to the terminal diagnosis, such as care for a broken bone or a separate infection.
The benefit is comprehensive and covers nearly all costs associated with the terminal illness, often resulting in little to no out-of-pocket expense. Covered services include nursing care, medical equipment, necessary medical supplies, and drugs for pain and symptom control. The benefit also covers four distinct levels of care:
- Routine home care
- Continuous home care during a crisis
- General inpatient care for symptom stabilization
- Short-term respite care for caregivers
This extensive coverage ensures that a patient’s medical needs are met wherever they reside, including a private home, assisted living facility, or nursing home.
Ohio Medicaid and Managed Care Options
For low-income Ohio residents, including those under age 65, the Medicaid program provides coverage for hospice services. Eligibility requires meeting specific state income and asset limits. Medicaid covers costs for dual-eligible individuals (qualifying for both Medicare and Medicaid), often covering copayments or deductibles that Medicare does not.
Medicaid services are designed for comfort and palliative care for terminally ill individuals. A key difference from Medicare is that patients under age 21 do not have to waive their right to curative services for the terminal condition. Adults, however, must waive Medicaid services for the cure and treatment of the terminal illness, similar to the Medicare rule.
The coordination of hospice services for many Medicaid beneficiaries is handled through Managed Care Organizations (MCOs). These MCOs are state-contracted health plans that manage care for the majority of Medicaid members. For beneficiaries in a nursing facility, MCOs are required to make room and board payments directly to the hospice provider. Hospice providers work closely with MCOs to coordinate care, sometimes requiring contracts to bill for services.
Private Insurance, VA Benefits, and Self-Pay
Beyond government programs, commercial health insurance plans, including employer-sponsored and marketplace coverage, cover hospice services. These private plans model their coverage after the federal Medicare Hospice Benefit, requiring a terminal prognosis and the shift from curative to palliative treatment. Coverage is comprehensive, but patients should review their specific plan for details on potential deductibles, copayments, or coinsurance.
Veterans may access hospice care through the Veterans Health Administration (VA) benefits package. Hospice is a covered benefit for enrolled veterans who meet the clinical need, and related expenses are covered at 100 percent with no copays. The VA works with community hospice agencies to provide this care, which can be delivered at home or in an inpatient setting.
Self-pay is an option for services not covered by insurance. Many non-profit hospice organizations utilize charity care funds and community donations to cover costs, providing care regardless of a patient’s ability to pay. These organizations work with patients and families to determine a fee structure that is not a financial burden, ensuring end-of-life care remains accessible.