Does Medicare Cover Palliative Care?
When dealing with a serious illness, the last thing you want to think about is finances. Instead, you and your loved ones should be fully focused on getting care that improves your quality of life and possibly slows or stops disease progression. Palliative care can achieve this, though it comes with medical bills. As a result, many people over 65 who consider this service find themselves asking, “Does Medicare cover palliative care?”
In short, both original Medicare and Medicare Advantage cover palliative care. Different parts of Medicare and types of Medicare plans, however, provide varied coverage for inpatient palliative care, outpatient services, mental health services, prescription medication, and other services for this care approach. Continue reading for everything you need to know about Medicare coverage for palliative care.
Key takeaways
Palliative care is a medical approach for those with a serious illness. It focuses on the individual’s comfort, improving their quality of life, and reducing symptoms. Patients can also simultaneously receive treatments to stop or slow disease progression.
Medicare does cover palliative care, provided a referring physician submits the necessary documentation for pre-approval.
Whether you have Medicare Advantage or original Medicare influences what coverage looks like. Advantage plans may cover more services, while original Medicare has a larger network of in-network specialists to choose from.
What is palliative care?
Palliative care is a medical field focused on optimizing quality of life, reducing physical symptoms, and addressing the emotional, social, practical, and spiritual concerns of patients with serious illnesses that may not necessarily be life-threatening. It’s also an option for potentially terminal illnesses, such as:
Cancer
Kidney failure
Dementia
Alzheimer’s disease
HIV/AIDS
Amyotrophic lateral sclerosis (ALS)
Heart disease
Lung diseases
This isn’t an exhaustive list, though these are some of the most common conditions referred to palliative care.
The care itself is delivered by a team of medical professionals who are all experts in their respective fields. The team may also comprise a social worker and a chaplain. Services are delivered in a hospital, nursing home, palliative care facility, or at an individual’s home.
Palliative services address physical problems through medication, physical therapy, and nutrition, and mental health problems through services like talk therapy and support groups. A palliative care team can also help you navigate practical problems, such as connecting you with transportation services or explaining complex medical terms.
Palliative care is often confused with hospice care, though the two aren’t the same thing. While both are intended for serious illnesses, hospice care focuses on comfort as someone approaches the end of their life. It’s most often offered when doctors predict someone may have less than six months left.
Palliative care, on the other hand, can begin as early as diagnosis and focuses on finding ways to manage symptoms and side effects, with the aim of improving the patient’s quality of life.
Does Medicare cover palliative care?
Medicare does cover palliative care, but since this service is interdisciplinary, different parts of Medicare cover specific services. Out-of-pocket costs for beneficiaries include monthly premiums for Parts B and D, deductibles, copays, and coinsurances.
Medicare Part A
Medicare Part A offers coverage for inpatient care at hospitals and skilled nursing facilities. It may also cover some home health services associated with palliative care. Depending on what services are necessary, there may be some out-of-pocket costs, such as coinsurance or copays.
Medicare Part B
Not all palliative care is delivered in inpatient settings. Doctor’s visits, medical equipment, and other outpatient services are covered by Medicare Part B. This part will also cover any outpatient mental health services you need, such as talk therapy or a therapist-led support group.
Medicare Advantage (Part C)
When enrolling in Medicare, you or a loved one have two options: select Original Medicare, which is run by the federal government and includes Medicare Parts A & B, or Medicare Advantage, also called Part C, which is when a private insurance company offers a Medicare plan that meets or exceeds the required components of Parts A and B.
Medicare Advantage offers a few unique benefits. The first is the potential for better care coordination if the Advantage provider utilizes a managed care model, an approach where insurance is integrated within a hospital system. UPMC for Life in Pennsylvania is a good example of this model. Many plans also offer additional benefits, like covering the cost of transportation to and from appointments and/or over-the-counter prescriptions.
Keep in mind that Medicare Advantage plans often have a smaller pool of in-network providers, meaning you may have fewer options for who provides care or might have difficulty getting services if traveling to another state.
Medicare Part D
While Part B offers limited funds for prescription medications, most beneficiaries get prescription drug coverage through Medicare Part D. This part is optional, and it comes with an additional monthly premium. You also don’t automatically get it when enrolling in Medicare; it’s a service you must opt into. For those on palliative care, Part D eases the financial burden of any prescriptions your care team might prescribe.
How to access palliative care through Medicare
Typically, a provider that regularly sees a patient, such as their oncologist or primary care provider, will refer them to palliative care. When there hasn’t been a referral, you can discuss if it’s a good fit with the provider who has the most knowledge about your or a loved one’s illness.
Finding palliative care providers
When referring to palliative care, the recommending provider will often suggest one or more facilities. If you want to widen your search, the National Hospice and Palliative Care Organization website offers a search engine to find palliative care providers.
Since this care is intensive, consider your comfort level with a specialist and whether your Medicare plan covers their services before committing to a palliative care provider. When meeting with a potential specialist, you can be upfront and ask any questions. Palliative specialists have additional training in how to communicate about challenging conditions and hold space for a patient and their loved ones’ emotions.
Specific questions you might ask are:
How do you balance symptom management with maintaining a good quality of life?
How are patients and their loved ones involved in care decisions? What role will I have in developing my care plan?
What specific services will you provide? What other types of healthcare providers will I work with?
How often will we meet, and what can I expect from those appointments?
What is your strategy for helping patients and their loved ones navigate decisions about treatment goals or end-of-life preferences?
Important coverage factors to consider
For Medicare to cover palliative care services, another provider usually has to refer you to this type of treatment. If on a Medicare Advantage plan, you’ll also want to find a palliative care specialist who is in-network. These providers are already in your insurance provider’s system and often require less administrative paperwork for you, as well as lower copays and coinsurances than out-of-network providers.
Getting palliative care coverage
For Medicare to cover palliative care, a doctor must first conduct a thorough consultation, documenting the ways in which this service will help minimize symptoms and improve a patient’s quality of life. Once they have that necessary paperwork, they’ll submit it to Original Medicare or your Medicare Advantage provider.
The insurance verification and approval process can take a few days to weeks, depending on whether additional documentation is required and an individual’s specific medical needs. Starting this process early and planning ahead are important, as they ensure a smooth transition to palliative care and avoid any delays.
Bottom line
Medicare covers palliative care when deemed medically necessary. To get the most from your coverage, choose the right Medicare plan for you, either via Original Medicare or Medicare Advantage, and check that your doctor submits the necessary paperwork for the care approval process. If there hasn’t been a referral to palliative care, discuss this option with the provider most involved in caring for the serious illness in question.
Frequently asked questions
What palliative care services does Medicare cover?
Medicare covers many palliative care services, including inpatient care, doctor’s visits, outpatient care services, mental healthcare, and some prescription medications. Some plans may cover more, such as transportation costs or over-the-counter drugs, so be sure to check your plan’s details.
Is there a difference between Medicare coverage for palliative care and hospice care?
Medicare covers more for hospice care than for palliative care. For the former, it covers the full costs, including medical supplies and services. For the latter, it covers services and supplies as it would any other medical service, meaning the individual is still responsible for deductibles, copays, and coinsurances.
How much does palliative care cost with Medicare?
Medicare covers many expenses associated with palliative care, which greatly reduces the cost. However, the individual is still responsible for their monthly Part B and D premiums, as well as their deductible, copays, and coinsurances.
Sources
National Center for Biotechnology Information (2023). Palliative care. https://www.ncbi.nlm.nih.gov/books/NBK537113/
National Library of Medicine (2024). What is palliative care? https://medlineplus.gov/ency/patientinstructions/000536.htm
National Institute of Aging (2021). What are palliative care and hospice care? https://www.nia.nih.gov/health/hospice-and-palliative-care/what-are-palliative-care-and-hospice-care
Centers for Medicare and Medicaid Services (n.d.). What Part A covers. https://www.medicare.gov/providers-services/original-medicare/part-a
Centers for Medicare and Medicaid Services (n.d.). Home health services. https://www.medicare.gov/coverage/home-health-services
Centers for Medicare and Medicaid Services (n.d.). What Part B covers. https://www.medicare.gov/providers-services/original-medicare/part-b
Centers for Medicare and Medicaid Services (n.d.). Medicare Advantage and other health plans. https://www.medicare.gov/health-drug-plans/health-plans
Centers for Medicare and Medicaid Services (n.d.). What’s Medicare drug coverage (Part D)? https://www.medicare.gov/health-drug-plans/part-d
National Alliance For Care At Home (n.d.). Find a provider. https://allianceforcareathome.org/find-a-provider/