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Everything Physicians Should Know About Palliative Care Medicare Coverage


Article-Everything-Physicians-Should-Know-About-Palliative-Care-Medicare-Coverage

Basics of Palliative Care

Palliative care plays a crucial part in improving the physical, mental, social, and spiritual quality of life for those with serious or life-threatening illnesses. When diagnosed with a serious illness, Medicare beneficiaries might choose to receive palliative care in addition to any other ongoing treatments. In this case, palliative care aims to maintain quality of life throughout the illness. Palliative care Medicare coverage includes long-term illnesses and hospice care for terminal illnesses. Billers often confuse between palliative care and hospice care. If a patient has been diagnosed with a terminal illness with less than 6 months to live, they may seek hospice care. Medicare beneficiaries with serious illnesses can choose palliative care to retain as much of their quality of life as possible.

Palliative care addresses patient’s physical, intellectual, emotional, social, and spiritual needs. Palliative care supports with independence, access to information, and the ability to make choices about their health care. Working with a palliative care specialist allows Medicare beneficiaries with serious illnesses to maintain their physical, emotional, and spiritual quality of life. Palliative care Medicare coverage includes inpatient care, outpatient care, and mental health counseling. Some of the serious illnesses that may benefit from palliative care include Alzheimer’s disease; amyotrophic lateral sclerosis (ALS); cancer; chronic obstructive pulmonary disease (COPD); congestive heart failure; dementia; end-stage liver disease; end-stage renal disease; HIV/AIDS; Huntington’s disease; multiple sclerosis; Parkinson’s disease; sickle cell anemia; stroke.

Palliative Care vs. Hospice Care

The slight difference between palliative care and hospice care as follows:

  • Hospice care: Hospice care is end-of-life medical care that provides emotional and physical support for patients with terminal illnesses. It is reserved for those with a life expectancy of 6 months or less. It focuses on relieving the symptoms of the illness, supporting the person’s emotional and spiritual health, and helping with any important decisions regarding the end of life. When you receive hospice care, it takes the place of any curative or life-prolonging treatments you would otherwise receive.
  • Palliative care: This focuses mainly on improving patient’s well-being in case of having a serious illness. Palliative care offers a support system to patients and their families so they can continue to have a good quality of life. Unlike hospice care, Medicare beneficiaries in palliative care continue to undergo curative or life-prolonging treatments.

Palliative care and hospice care both focus on supporting overall well-being when the patient has a serious illness. However, hospice care is reserved for the end of life, when patients have chosen not to have any further treatments to cure their illness.

Palliative Care Medicare Coverage

Original Medicare and Medicare Advantage both cover palliative care, both with and without hospice care, when it’s deemed medically necessary. Here’s what each part of Medicare covers:

Medicare Part A Palliative Care Coverage

Medicare Part A is hospital insurance. It covers many of the inpatient and skilled care needed with palliative care. Under Part A, Medicare beneficiaries are covered for:

  • Inpatient hospital stays: This includes any treatments or services Medicare beneficiaries might need during their stay.
  • Short-term stays at an SNF: Services include rehabilitation services, medication administration, and other day-to-day care.
  • Limited home health care includes part-time skilled nursing or home health aide care and rehabilitation services.
  • Hospice care: Medicare beneficiaries are covered for any palliative care necessary for comfort at the end of life.

Medicare Part B Palliative Care Coverage

Medicare Part B is medical insurance. It covers most of the outpatient services that are needed during palliative care. With Part B, Medicare beneficiaries are covered for:

  • Doctor’s appointments: These may be needed for the diagnosis, treatment, and prevention of the illness or other related conditions.
  • Durable medical equipment: This includes any equipment that may be needed for treatment or to make patients more comfortable.
  • Mental health counselling: Emotional support and counseling may be needed for patients or their loved ones during your care.
  • Rehabilitation therapy (as an outpatient): This includes speech therapy, physical therapy, or occupational therapy as needed.

Medicare Advantage Palliative Care Coverage

Medicare Part C is also known as Medicare Advantage. This is a Medicare option sold by private insurance carrier companies. With Medicare Advantage, Medicare beneficiaries are automatically covered for the same services as Medicare Part A and Part B, including those for palliative care. Under Medicare Advantage, Medicare beneficiaries might be covered for some additional services, such as:

  • Prescription drugs: These may be for treatment or to help ease any symptoms.
  • Long-term care may include skilled healthcare services or help with everyday personal needs, such as bathing, dressing, or eating.

Private payers that sell Medicare Advantage plans may also offer different plan options to fit individual needs. For people with serious illnesses, Special Needs Plans (SNPs) offer additional medical services and flexibility that may better for long-term or serious conditions.

Medicare Part D Palliative Care Coverage

Medicare Part D is prescription drug coverage. Part D may cover medications needed during palliative care. Some of the conditions during palliative care for which medications are prescribed are anorexia, anxiety, constipation, delirium, depression, diarrhea, dyspnea, fatigue, mucus buildup, nausea, pain, and vomiting. Medications for these conditions may include antidepressants, anxiolytics, antipsychotics, stool softeners, antidiarrheals, and opioid and nonopioid analgesics. If Medicare beneficiaries are receiving hospice care, most medications are covered under the hospice benefit with a $0 to $5 co-payment per prescription drug. Medications that aren’t covered under the hospice benefit may still be covered under a Medicare Part D plan.

Receiving Palliative Care

When a patient is diagnosed with a serious illness, the primary care physician helps to get in touch with a palliative care specialist. Palliative care specialists help build a team of other specialists to coordinate the many aspects of patient care. The palliative care specialist will review this information to create a personalized team and plan. For example, a palliative care team may include a palliative care doctor, counsellor, pharmacist, and dietitian. Working together, they may create a plan that involves weekly therapy sessions, a specialized medication plan, and a personalized meal plan. All of these services can help increase your quality of life during a patient’s illness.

If Medicare beneficiaries are receiving palliative care without hospice care, they’ll owe standard Medicare out-of-pocket costs. These costs generally include:

  • Deductibles: In 2020, Medicare beneficiaries were paying $1,408 per benefit period for Part A and $198 per year for Part B.
  • Co-payments: These may include out-of-pocket costs for prescription drugs and Medicare Advantage doctor’s visits and specialist visits.
  • Coinsurance: Depending on the length of inpatient care, Medicare beneficiaries might pay some coinsurance costs each day under Part A, 20 percent of the costs for services under Part B, and any costs related to prescription drugs.
  • If the beneficiary has a Medicare Advantage plan, they may also owe additional premium, deductible, co-payment, and coinsurance costs.

Medicare beneficiaries who are seeking for palliative care can get in touch with your doctor who can further help in getting connected with palliative care experts. Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. In this article, we shared essential information on palliative care Medicare coverage for provider education purposes. Primary care physicians who are seeking assistance in medical billing and coding can call us at: 888-357-3226 or drop an email at info@medicalbillersandcoders.com.

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