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Our purpose on this page is to provide general information to help you understand how most hospice care insurance providers operate.  You should contact your specific provider to ensure you understand your eligibility for hospice, the hospice care coverage available to you and any deductible or co-payment responsibilities you may have. 

Because we’ve added a lot of information to this page, you may find some of the topics of less interest than others.  To save your time and effort, you can use the following “jump station” to go immediately to the topic(s) most appropriate to your situation.

1.         Medicare

2.       Medicaid  (This technically is not insurance.  However, it does provide financial assistance
          to low income families who do not have any other insurance coverage.)
3.       Private Insurance
4.       Private Pay

Medicare

After you read this section on Medicare page, please visit www.medicare.gov or call 1-800-Medicare (633-4227) to learn about, and ensure you understand, your specific eligibility status and the benefits to which you are entitled.  You may also find this Medicare pamphlet at http://www.medicare.gov/publications/pubs/pdf/10050.pdf  helpful.

Medicare is a government health insurance program administered by the U. S. Department of Health and Human Services through the Centers for Medicare & Medicaid Services (CMS).  It is the largest health insurance service in the country with over 50 million Americans participating. 

Medicare was established under Title XVIII of the Social Security Act.  It was signed into law in 1965 by President Lyndon B. Johnson.  (Some quick trivia:  At the bill-signing ceremony President Johnson enrolled former President Harry S. Truman as the first Medicare beneficiary.  His wife, Bess, received the second card.)

Medicare Eligibility

Most people age 65 or older who are citizens or permanent residents of the United States are eligible for free Medicare hospital insurance (Part A).  You are eligible at age 65 if:

  • You receive or are eligible to receive Social Security benefits. 

You become eligible after you have contributed to your Social Security account and paid Medicare taxes through payroll deductions for a total of ten years (forty quarters).  The forty quarters do not have to be consecutive or with the same employer.

  • You receive or are eligible to receive railroad retirement benefits; or
  • You have worked long enough (once again, ten years) in a government job where you have paid Medicare taxes through payroll deductions; or
  • You are the dependent parent of a fully Medicare-insured deceased child.

These same eligibility rules apply to spouses, which means if either spouse (living, deceased or divorced) has worked for ten or more years in jobs that paid into the Social Security and Medicare systems, both are covered.

Before age 65, you are eligible for free Medicare Part A hospital insurance, if:

  • you have been entitled to Social Security disability benefits for 24 months; or
  • you receive a disability pension from the Railroad Retirement Board and meet certain other conditions; or
  • you receive Social Security disability benefits because you have Lou Gehrig’s disease (amyotrophic lateral sclerosis); or
  • you worked long enough in a government job where Medicare taxes were paid and you meet the requirements of the Social Security disability program; or
  • you are the child or spouse (including a divorced spouse) of a person (living or deceased) who:
  • worked long enough to qualify for Social Security or
  • worked long enough in a Medicare-covered government job where Medicare taxes were withheld and
  • you are 50 or older and
  • you meet the requirements of the Social Security disability program; or
  • you have permanent kidney failure and you receive maintenance dialysis or a kidney transplant and:
  • You are eligible for or receive monthly benefits under Social Security or the railroad retirement system or
  • You have worked long enough in a Medicare-­covered government job where Medicare taxes were withheld

As mentioned earlier, if you or your spouse has paid Medicare taxes for at least ten years, you usually don't pay a monthly premium for Part A coverage. This is called "premium-free Part A."

However, if you aren't eligible for premium-free Part A (most likely because you have not met the ten year contribution requirement), you may be able to buy Part A insurance if you meet one of these conditions:

  • You're 65 or older, you're entitled to (or enrolling in) Part B, and you meet the citizenship or residency requirements.
  • You're under 65, disabled and your premium-free Part A coverage ended because you returned to work.

In most cases, if you choose to buy Part A, you must also have Part B and pay monthly premiums for both.  You should speak with a Medicare representative to determine your Part A status and any premium costs you might be responsible for.  If you have limited income and qualify for Medicaid, your state may help you pay the premiums for Part A and/or Part B.

Medicare provides the following coverage.

Part A (Hospital Insurance)

Part A helps cover:

1.       Inpatient care you receive in:

  • acute care hospitals
  • critical access hospitals
  • long-term care hospitals
  • inpatient rehabilitation facilities
  • inpatient care as part of a qualifying clinical research study
  • mental health care facilities

            Inpatient care includes:

  • semiprivate room and meals
  • general nursing
  • medications
  • other necessary hospital services and supplies


            These inpatient services are not included:

  • private duty nursing
  • in-room televisions or telephones
  • private rooms, unless medically necessary
  • personal care items, such as razors or slipper socks

      Note that inpatient mental healthcare in a psychiatric facility is limited to 190 days in a lifetime.

2.       Skilled nursing facility care following a related three-day inpatient hospital stay and
           typically for the purpose of rehabilitation includes:

  • a semiprivate room and meals
  • skilled nursing and rehabilitative services
  • other necessary services and supplies

3.       Home healthcare

Home healthcare is limited to care and services to those who are homebound (meaning that leaving home is a major effort) and is:

  • ordered by your doctor
  • considered to be reasonable and necessary
  • provided by a Medicare-certified home health agency

      Home healthcare includes:

  • part-time or intermittent skilled nursing care
  • home health aide services
  • physical therapy,
  • occupational therapy
  • speech-language pathology that are ordered by your doctor

            Home healthcare also covers:

  • medical social services
  • durable medical equipment, including wheelchairs, hospital beds, oxygen, etc.
  • medical supplies and other services

4.       Blood

In most cases, a hospital gets blood from a blood bank at no charge and you don't have to pay for it or replace it.  If the hospital has to buy blood for you, you must either pay the hospital costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else. After that, Medicare will cover any costs for blood and transfusions.

5.       Inpatient care in religious nonmedical health care institutions

Please go here (start with Subpart G at the bottom of the second column of the page) to begin your research on this coverage.

6.       Hospice Care

If you meet specific medical criteria, you are eligible for the Medicare Hospice Benefit. 

Our clients who qualify for the Medicare Hospice Benefit receive hospice care at no cost.  Medicare fully reimburses us for the hospice care services we provide and we do not ask for the Medicare approved co-payments for our services.  In other words, neither Medicare nor we ever ask for any kind of payment for the hospice care our Medicare clients receive. 

When you do your research prior to choosing a hospice agency, be sure to ask the question, “Do you charge the co-pays?”, since some hospice agencies still do.

          Hospice Eligibility

          A person is eligible for the Medicare Hospice Benefit if he or she:

  • is eligible for Medicare Part A
  • is certified to have a life-limiting illness or condition by his or her primary physician and the hospice Medical Director
  • elects to discontinue curative treatments of the disease or condition and receive only treatment that eases pain and discomfort (palliative care)
  • receives care from a Medicare-certified hospice agency, such as Autumn Journey Hospice

          The Medicare hospice benefit includes:

  • physician services related to the life-limiting illness or condition
  • regular home care visits by a registered nurse
  • non-denominational chaplain visits and services for the client and the family, as desired
  • social worker visits and counseling services
  • visits by a certified nurse aide to assist with activities of daily living, such as dressing and bathing
  • medical equipment including, but not limited to, a walker, wheelchair, shower stool, hospital bed with alternating air pressure mattress and oxygen
  • medical supplies ranging from adult diapers to catheters to wound control materials
  • prescription medications to control symptoms and relieve pain related to the hospice diagnosis
  • dietary counseling
  • any therapy that may be necessary
  • respite care when needed
  • bereavement counseling

          Please note that Medicare Hospice Benefit does not cover the following types of care:

  • Treatment to cure a life-limiting illness or condition is not covered.

    The philosophy of the Medicare Hospice Benefit is to provide comfort care rather than curative treatment.  Medicare beneficiaries elect to receive palliative care to help ease pain and discomforting symptoms rather than trying to cure an illness or condition.  By accepting the hospice benefit of Medicare, an individual waives Medicare coverage for any curative treatment of the life-limiting illness or condition. 
  • Care from two hospice providers simultaneously is not covered.

    An individual must elect to receive service from a single hospice care provider.  However, he or she may transfer hospice care from one hospice care provider to another at any time.  Transfers like this sometimes are done when the client is dissatisfied with the service he/she is receiving or moves out of the area served by a hospice agency.  Transfers are done entirely at the discretion of the client, require no justification or reason and do not result in loss of the hospice care benefit.
  • Room and board in hospice facilities, skilled nursing facilities, residential assisted living homes, retirement homes or other similar facilities is not covered.

In certain situations, Medicare does pay for stays in skilled nursing facilities. However, this is done primarily for physician prescribed rehabilitation and requires the individual to enter the facility directly from the hospital.  This coverage for rehabilitation purposes should not be confused with hospice care coverage under the Medicare Hospice Benefit.

We are often asked if there are hospice facilities where the Medicare Hospice Benefit pays for room and board.  The answer, unfortunately, is no.  Some of the larger hospice organizations who have hospice agencies nationwide also own inpatient hospice facilities and skilled nursing facilities.  However, since Medicare only pays for the care provided under the Hospice Benefit, you will have to pay for any services not related to hospice care, in particular room and board charges. 

Regardless of place of residence, the individual receiving hospice care provided by Medicare is always responsible for the cost of room and board. 

  • Care provided by companion caregivers, aides, attendants, sitters or homemakers is not covered.

Another basic philosophy of the Medicare Hospice Benefit is that primary hands-on care (sometimes referred to as companion care or sitter care) is provided by the spouse, significant other, partner, family members or other loved ones.  The Medicare Hospice Benefit does not provide these services.  Unless you have private insurance that provides coverage for these services, you will be responsible for their costs.

Part B (Medical Insurance)  

Part B coverage includes:

  • physician and nursing services
  • x-rays, laboratory and
  • diagnostic tests
  • influenza and pneumonia vaccinations
  • blood transfusion,
  • renal dialysis
  • outpatient hospital procedures
  • limited ambulance transportation,
  • immunosuppressive drugs for organ transplant recipients
  • chemotherapy
  • hormonal treatments
  • other outpatient medical treatments administered in a doctor's office

Some physical or occupational therapies and some home health care services are also covered.  Medication administration is covered under Part B only if it is administered by the physician during an office visit.

Part B also helps with:

  • durable medical equipment (DME), including canes, walkers, wheelchairs and mobility scooters for those with mobility impairments
  • Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy
  • as well as one pair of eyeglasses following cataract surgery
  • oxygen for home use are also covered
  • some preventive services

Anyone who is eligible for Part A can enroll in Part B by paying a monthly premium.  Some beneficiaries with higher incomes will pay a slightly higher monthly Part B premium.  You should speak with a Medicare representative or visit the Medicare website to understand what your premium will be.

If you want to enroll in a Medicare Advantage Plan (see below), you must be enrolled in both Medicare Part A and Part B.  Why?  We don’t know, but here’s what Medicare says:

You don't have to take Part B coverage if you don't want it, and your Advantage plan sponsor can't require you to take it. There are some advantages to enrolling in Part B:

  • You have the advantage of coordination of benefits between Medicare and your Advantage plan, reducing your out-of-pocket costs.
  • Your Advantage plan insurer may waive its copayments, coinsurance, and deductibles for Part B services.
  • Some services covered under Part B might not be covered or only partially covered by your plan, such as orthopedic and prosthetic devices, durable medical equipment, home health care, and medical supplies (check your plan brochure for details).
  • You may go outside of the plan's network for Part B services and receive reimbursement by Medicare (only when Medicare is the primary payer) If you are enrolled in an Advantage plan HMO.

Part D (Prescription Drug Coverage)

Anyone who has Medicare Part A or B insurance is eligible for prescription drug coverage. Your decision to us a Medicare prescription drug plan is voluntary.  You will pay an additional monthly premium for this coverage.  Note that to get prescription drug coverage through a Medicare Advantage Plan (see below), you must be enrolled in Medicare Part A and Part B.

Unlike Original Medicare Part A and B, Part D coverage is not standardized.  There are a number of Part D plans and each determines which drugs (or even classes of drugs) are covered, what level (or tier) is covered and whether some drugs are covered at all. The exception to this is drugs that Medicare specifically excludes from coverage, currently including but not limited to benzodiazepines, cough suppressant and barbiturates.

Once again, you should speak with a Medicare representative or visit the Medicare website to understand what drug plans are available and what you can expect your premium to be.

Part C (Medicare Advantage Plans) 

We’re going to touch very briefly on Medicare Advantage plans, particularly as they relate to hospice coverage and care.  We are providing only an extremely brief description of these types of plans, so please do your own research and due diligence to help you to decide whether an Advantage Plan is right for you.

More than ten million Americans use Medicare Advantage Plans and receive their Part A and Part B benefits from private health insurance providers rather than directly from Medicare.   Secure Horizons, owned by United Healthcare, is one of the most well known plans in Texas, although other private insurers offer similar plans.

These private insurance providers are approved by and have contracts with Medicare.  Each of their Medicare Advantage plans is a type of private hospitalization and medical insurance coverage that you may elect to use instead of your Medicare insurance coverage.   Each plan must meet or exceed Medicare standards. 

These plans offer the same coverage as Original Medicare Parts A and B.  They also may offer extra benefits like annual physicals, dental care, vision care and access to a nurse helpline.  Some (but not all) may include a prescription drug plan.   Many plans offer a cap on your annual out of pocket spending.

Most Advantage Plans require you to use the doctors or hospitals on the provider’s network.  Advantage Plan providers typically use one or more of the following methods to deliver care services to you.

  • Health Maintenance Organizations (HMOs)
  • Preferred Provider Organization (PPO)
  • Private Fee for Services (PFFS)
  • Special Needs
  • Medicare Savings Accounts (MSA)

Medicare Advantage providers are paid by Medicare and in some cases also charge premiums to their clients depending on the type of plan and extra coverage the client chooses. 

Generally, Medicare Advantage plans are open to anyone who is eligible for Medicare and lives in the service area of the plan, regardless of health (with the exception of those with end stage renal disease). There are no physicals or health questions. You cannot be refused coverage and your premium cannot be increased if you have pre-existing conditions that might put you at a greater risk.

You can go to https://www.medicare.gov/find-a-plan/questions/home.aspx to find the Advantage plans available in your area.

To enroll in a Medicare Advantage Plan, you must be enrolled in both Medicare Part A and Part B.  If you enroll in an Advantage Plan, you will have to continue paying your monthly Medicare Part B premium to Medicare. In addition, you may have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer, depending on the plan you choose.

Also, please note, if you have Medigap insurance and enroll in a Medicare Advantage Plan, your Medigap policy is not compatible and cannot be used. This means Medigap will not pay any deductibles, copayments, or other cost-sharing as it would have if you were using the standard Medicare health care coverage. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan.  However, you have a legal right to keep the Medigap policy if you wish to do so.

When you join a Medicare Advantage Plan, you will use the health insurance card issued by the plan provider for your health care rather than your Medicare card.  You will only use your Medicare card for hospice care.

As you consider your interest in an Advantage Plan, please keep this in mind.  Advantage Plans are helpful to Medicare because Medicare pays the plan provider less than it would pay to hospitals and physicians for your care and services.  So, the plan provider receives less and must still generate a profit.  It can only do this by keeping you in its network of hospitals and physicians who are willing to accept even less than Medicare pays to them. 

We have no idea whether or not quality of care is affected, but it is an issue you should consider and research before you make your decision to use an Advantage plan.  You may want to talk with others who are on Advantage plans to see how they feel about the care and services they are receiving through their plan.

Medicare Advantage Plans and Hospice

It’s important to know and understand that none of the Medicare Advantage plans provide hospice care.  Hospice care is only available under your basic Medicare Part A benefit.

If you qualify for hospice and begin receiving hospice care under Medicare Part A, what affect does that have on your coverage under your Medicare Advantage plan?

The short answer is your existing Medicare Advantage plan is not affected in any way. You have the following rights and benefits in your Medicare Advantage plan.

  • You may elect to receive hospice at any time through your Medicare Part A Hospice Benefit according to the Medicare regulations governing hospice care.
  • Your Medicare Advantage plan must, according to the agreement between the plan provider and Medicare, continue to provide all Medicare related services it had been providing as long as those services are not related to your hospice diagnosis.
  • Your Medicare Advantage plan also must, according to the agreement between the plan provider and Medicare, continue to provide any additional benefits included in your plan as long as they are not related to your hospice diagnosis.

So, if you receive hospice care, you will use your Medicare card.  However for all of your other health care you will still continue to use the card issued by your Medicare Advantage plan provider.

Medicaid

Please note that the information contained in this section is meant only to acquaint you with general information about the Texas Medicaid program.  Other than the telephone contact numbers and website address, you should not use any of the limited information provided here to make any decisions related to Medicaid eligibility or services. 

Medicaid was established in 1965, at the same time as Medicare, under Title XIX of the Social Security Act.  It was designed to assist low-income families by providing health care services for them and their children.  It also provides health care services for qualified individuals who fall below the federal poverty level.  Currently it provides assistance to over three million Texas residents.

Medicaid is a State and Federal cooperative program which is administered in Texas by the Texas Health and Human Services Commission.  Medicaid covers hospital and physician visits, emergency room visits, hospice care, drugs, other treatments and services, and in some cases pays for Medicare coverage.  In certain situations, Medicaid also helps recipients by paying all or some portion of the room and board costs in Medicaid approved skilled nursing facilities.

Medicaid recipients who are medically qualified can receive hospice care at no cost.  As a hospice agency that works with Medicaid, we look only to Medicaid for reimbursement for the services and never request payments of any kind from our Medicaid clients.

Please be aware that Medicaid programs are different in every state.  You must check with your own state to determine eligibility requirements and the assistance available.

The 2010 general financial requirements for an individual to be eligible for Medicaid assistance in Texas are: (1) gross monthly income from all sources may not exceed $2,022 and (2) total assets may not exceed $2,000.  These requirements are subject to change each year.   

However, before you abandon Medicaid as a possible resource because you or your loved one may exceed either or both financial requirements, you should be aware there are, for lack of a better term, “work arounds” for both criteria.  Thanks to these “work arounds” there are mechanisms available that may still enable you or your loved one to qualify for Medicaid assistance.

Regardless of your or your loved one’s financial situation, we strongly recommend you contact Medicaid by one of the methods described below.  You can explain the financial situation and assistance needed in detail and the Medicaid representative will determine whether you or your loved one is eligible for Medicaid assistance. 

The representative will be aware of the “work arounds” we are rather vaguely referring to and will explain them to you.  If the representative doesn’t mention anything, ask if a Miller trust would help you meet the monthly income requirement.  Also ask if home ownership will disqualify an individual from Medicaid assistance.  These questions should start the discussion about the “work arounds.”

We would also strongly recommend you consult an attorney who is knowledgeable and experienced in elder care issues, in particular Medicaid eligibility issues (including Miller trusts). It will be worth the two or three hours of legal fees to get a better understanding of the Medicaid regulations and the ways in which Medicaid may be an option for you.

We apologize for our rather circumspect approach to our description of the Texas Medicaid program.  However, the truth of the matter is the Medicaid program and process is convoluted, complex and difficult for the general public, including us, to understand. 

To add to the problem, the Texas Medicaid program provides a wide variety of services…..and many of the services appear to have their own unique eligibility requirements.  As a result, specific eligibility requirements for some services can be difficult to determine because you must search for answers in one or more Medicaid reference publications. 

Because of this, we frankly are uncomfortable attempting to serve as a resource of detailed information about Medicaid.  However, we can guide you to resources that should be able to answer your questions about Medicaid assistance.

Your local Texas Health and Human Services Commission office can explain the Medicaid program and its eligibility requirements.  Representatives can also provide a list of the services available and the contact numbers for the service agencies of interest to you.   Please note that one of the services available under the Medicaid Community Based Alternative (CBA) programs is in-home companion/sitter care, typically for two to eight hours a day.   You can ask for more information about this program as part of your discussion with the Medicaid representative.

You can find your local Commission office by visiting https://www.211texas.org/211/.  You can also use your telephone to dial 211, which serves as a customer service call center, to help you find community resources and services, including Medicaid.  If you prefer, you can call the Medicaid Client Hotline directly at (800) 252-8263. 

You can also visit http://www.hhsc.state.tx.us/medicaid/med_info.html for information about the Texas Medicaid program.  For information on general elder care issues and their solutions, the website at http://www.dads.state.tx.us/ownyourfuture/info.html could be helpful to you.

Medicaid may be a useful option if you are seeking hospice care for a loved one who has limited income and assets.  Many elderly people end up in this situation, even though they enjoyed successful careers, due to situations such as losses in investments and/or high health care expenses that have used up their savings.

We want to add one additional caution about long term care (i.e., nursing homes) funded through Medicaid.  Medicaid’s assistance with monthly room and board payments to skilled nursing facilities sounds like a wonderful solution to the problem of financing long term care.  However, we urge you to conduct in depth inspections of the Medicaid facilities available before you choose one for yourself or your loved one. 

Medicaid facilities typically receive monthly reimbursements slightly in excess of $3,000.  In contrast, the private nursing home down the street will charge anywhere from $4,500 to $6,000 per month.  You can draw your own conclusions about the amount and quality of care, plus amenities offered and the condition of each of these facilities. 

Lost in all of this is the fact that we provide the same services, prescription medications, medical equipment, medical supplies and level of care to our Medicaid clients as we do for our Medicare clients. 

Private Insurance and Managed Care

There are many private insurance carriers and each typically offers a number of different insurance plans.  As a result, we can’t really summarize or characterize the hospice coverage you may be entitled to.  However, as a general observation, most private insurers pay hospice care providers between half and three quarters of the daily rate Medicare provides.  These rates are determined by the hospice providers’ status…..whether they are in the insurance carriers approved network or are “out of network”.   

Also, most private insurance carriers have a payment “cap” that typically is half of the Medicare “cap” amount. However, you don’t have to be concerned about this.  As a condition of being a provider for private insurance carriers, hospice care providers are required to provide the same amount, level and quality of care for clients who may exceed the “cap” amount.

You should consult with your insurance provider to determine the type and amount of coverage it provides for hospice care.  You also should ask about possible deductible and/or co-payment requirements.  It would also be a good idea to inquire about the policy’s hospice payment “cap”.  This will allow you to monitor your hospice provider more closely in the event the “cap” is exceeded to ensure your provider does not reduce or eliminate any needed or desired services.

We will work with you and your hospice benefit provider to maximize any hospice benefits available.  We provide the same services, prescription medications, medical equipment, medical supplies and level of care to our private insurance clients as we do for our Medicare/Medicaid clients.  

Private Pay

For those who may elect to do so, we also accept direct payment from the client for our services.

Once again, we provide the same services, prescription medications, medical equipment, medical supplies and level of care to our private pay clients as we do for our Medicare/Medicaid clients.

 

Autumn Journey Hospice
5347 Spring Valley Road
Dallas, TX 75254
Phone: 972.233.0525
Email: wecare@autumnjourneyhospice.com