Questions submitted by readers and answered by the CLL Society Medical Advisory Board
By Ed Ratner, MD
Does insurance cover palliative care or hospice?
Answer from Dr. Ratner: Hospice is a specific covered benefit in almost every insurance policy, including Medicare and Medicaid. In almost all cases, the eligibility and benefits follow the Medicare rules. Thus, eligibility is generally based upon physicians’ expectation of life expectancy for similar individuals of 6 months or less. Insurers make a daily payment to a hospice program which then covers all hospice related costs. For Medicare, that includes medications.
In contrast, palliative care is rarely a specified insurance benefit. Rather, palliative care services are provided within other benefits. For example, in the hospital or clinic, a palliative care specialist provider may offer services under the medical care benefits. Other team members (e.g. social work, chaplaincy) in such settings are only rarely separately compensated by insurance, but patients should not receive bills for their services. While receiving home health services, a home health agency may offer palliative care services provided by a nurse or social worker covered by the home health benefit.
Hospice programs are allowed to provide limited physician consultation services to people not enrolled in hospice under the Medicare benefits, to assist patients in deciding about end of life issues. This is relatively uncommon, however.
One important aspect of palliative care, advance care planning, is now reimbursed by Medicare and some other insurers to medical practices above and beyond the costs of the typical physician visit. Patients should ask their primary care practices and cancer clinics to assist them with completion of a health care directive, reminding them of the extra reimbursement available for that assistance. The billing code is 99497.
I have heard that hospice care can be for much longer than just for the last few days or weeks of life, but I don’t understand how that works and why I would ask for such services?
Answer from Dr. Ratner: Most people enroll in hospice for only a few days or weeks, but this is unfortunate. The comprehensive team approach offered by hospice programs is intended to make a person’s last months of life as good as possible and to relieve some burden from family caregivers. There is no limit to how long someone can be enrolled in hospice if they remain so ill that life expectancy going forward remains less than 6 months. For those dying from CLL, enrollment in hospice may be appropriate when it is clear that there are no more treatments available or desired by the patient. Such patients are typically symptomatic from anemia or infections and are likely to have had significant weight loss and fatigue. Yet, death from progression of CLL may be many weeks or months away. In the meantime, hospice is probably the best service available to avoid hospitalizations or emergency room visits, as hospice programs can provide 24 hour on-call services and urgent home visits. Unlike home health care benefits, hospice can provide home care assistance even if the patient wants to continue going out socially or even to work. The expensive drugs for CLL will almost never be covered by hospice. Transfusions are not prohibited by policy, but many hospices decline to cover them except in extraordinary situations.
As treatments have expanded and improved for CLL, most people with CLL are likely to die of other diseases. Hospice enrollment for heart or lung failure or neurological diseases does not preclude ongoing treatments (e.g. medications) for CLL. Hospice programs should not pay for medications for CLL if enrollment is for another condition.
Most hospice programs will provide free, no-obligation informational visits. Patients considering discontinuing treatment for CLL should discuss options and future care with a hospice program as part of the decision-making process.
Dr. Ratner is an internist who specializing in geriatrics and hospice/palliative care. He currently serves as Associate Director of the Geriatrics Education Research Clinical Center (GRECC) at the Minneapolis VA Medical Center and as an Associate Professor at the University of Minnesota Medical School. He is also a member of the CLL Society’s Hospice and End of Life Committee.
Originally published in The CLL Tribune Q2 2019.