Medicare For Dummies. Patricia Barry
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up treatments intended to cure your terminal illness.
Your doctor and the medical director of a hospice program must certify that you probably have less than six months to live.
You must enroll in a hospice program that Medicare has approved.
You must have Medicare Part A hospital insurance.
If you qualify, Medicare pays in full — 100 percent — for a wide range of services, including
Medical and nursing care, plus round-the-clock on-call support
Medical equipment and supplies
Homemaker and home health care services
Physical therapy
Social worker services and dietary counseling
Support for your caregiver
Grief and loss counseling for you and your family
Your share of the cost is limited to a maximum of $5 per prescription for drugs used to control the symptoms and pain of your terminal illness, and 5 percent of the cost of respite care if you’re taken into a nursing home to give your caregiver a break. However, if you have Medigap supplemental insurance, both these costs are fully covered, as Chapter 4 explains. (Costs related to any medical conditions other than your terminal illness are covered by Medicare Part B or Part D in the usual way.)
www.medicare.gov/Pubs/pdf/02154-Medicare-Hospice-Benefits.pdf.
Palliative care
Palliative care seeks to relieve the symptoms of pain and suffering associated with an illness that may not be terminal but is serious enough to be considered life-threatening. It focuses on improving the quality of life for patients and their caregivers. How is palliative care different from hospice? Well, palliative care does not require patients to give up attempts to cure their illness, and it can be administered at any time, without regard to how long they’re expected to live.
Medicare doesn’t recognize palliative care as a separate benefit. But Medicare may cover its components in other ways under Part B — for example, through the home health-care service described earlier in this chapter or through hospital outpatient departments. If you want to learn more about palliative care or find out where you can get it in your area, discuss local options with your doctor. The Center to Advance Palliative Care offers an online directory of hospitals that provide palliative care at https://getpalliativecare.org/providers/.
End-of-life care counseling
While nobody wants to be morbid, people are increasingly seeing the sense of drawing up plans for care at the end of their lives — to ensure that their own wishes are respected at that time, even if they’ve reached a point of illness where they’re unable to say what they want. Discussing with a doctor how to make those plans is known as end-of-life counseling, or advance care planning.
The counseling session may include information on making an advance care directive — a legal document in which you specify whether or not you want to continue treatment or be revived if close to death — and on giving someone (a family member, friend, or legal advisor) legal power of attorney to make medical decisions for you if you are incapacitated. It may also provide information about hospice and palliative care (which I cover earlier in this chapter).
Medicare has provided coverage for such discussions since the beginning of 2016 as a benefit you can choose to receive. As it’s voluntary, nobody can require you to take it, and if you are offered it but don’t want it, you’re free to decline, without forfeiting the right to take part sometime in the future. You can decide if and when the time is right to receive counseling: while you’re still well, with no health issues; when you become ill; or while you’re receiving hospice or palliative care.
Under this benefit, Medicare pays your doctor (or another authorized medical professional, such as a nurse practitioner) for a first counseling session of up to 30 minutes, and for further 30-minute sessions if you need them. There is no limit on the number of sessions, and they can take place in a variety of settings — doctors’ offices, hospitals, and nursing facilities, for example. If the counseling takes place during an annual wellness visit (which I describe in the earlier section on preventive care), the counseling is free, provided that the doctor accepts assignment. If you schedule a separate session outside the wellness visit, you pay the usual Part B co-pay and the Part B deductible is applied, unless you have supplemental insurance that covers these expenses.
Pregnancy and childbirth
Medicare does indeed cover pregnancy and childbirth. Are you astonished? That’s probably because you see Medicare as a program only for people way past childbearing age. But of course Medicare is also for much younger people who qualify through disability, and some of them become pregnant.
The relevant regulation in the Medicare Benefit Policy Manual explains the scope of coverage: “Skilled medical management is appropriate throughout the events of pregnancy, beginning with the diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.” Medicare also helps cover the cost of treatment for miscarriages and for abortions in circumstances where pregnancy is the result of incest or rape or would threaten your life if you went to term. It doesn’t cover elective abortion if you choose to terminate your pregnancy.
To receive hospital services, you need Part A hospital insurance. For doctors’ services and outpatient procedures (such as lab tests), you need Part B coverage. If you’re enrolled in Medicaid because your income is low, that program may pay some or all of your out-of-pocket Medicare costs, depending on your state’s eligibility rules. Medicaid may also pay for your infant’s medical care. But after the birth, Medicare doesn’t cover services for your baby at all.
Medical supplies and equipment
What if you need a wheelchair, an artificial limb, an oxygen tank, or other items that help you function but really qualify as things rather than services or treatments? Medicare has a suitably bureaucratic name for these things — durable medical equipment — and its meaning is precise. Durable means long-lasting, and Medicare covers only items that will stick around awhile. With only a few exceptions, it doesn’t cover disposable items that you use once or twice and then throw away.
To get Medicare coverage for durable medical equipment, it must be
Medically necessary for you, not just convenient
Prescribed by a doctor or another primary-care professional
Not easily used by anyone who isn’t ill or injured
Reusable and likely to last for three years or more
Appropriate for use within the home
Provided by suppliers that Medicare has approved