Medicare’s hospice benefit should cover any prescription drugs you need for pain and symptom management related to your terminal condition.
- You pay a $5 copayment for outpatient An outpatient is a patient who has not been formally admitted into the hospital as an inpatient. Most outpatient care is covered under Medicare Part B (medical insurance). pain and symptom management drugs.
- You pay nothing for drugs you receive as an inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance). during a short-term hospital or skilled nursing facility (SNF) stay.
Be aware that the hospice benefit will not cover medications that are not related to your terminal condition. Your stand-alone Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. plan or Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). drug coverage may cover medications that are unrelated to your terminal condition, but your plan’s coverage rules and cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. will apply.
After you elect hospice, Medicare assumes that medications prescribed to treat symptoms of pain, nausea, constipation, and/or anxiety are related to your terminal condition and should be covered by your hospice provider, not your Part D plan. If you do not need these kinds of drugs to treat your terminal condition—but do need them to treat other conditions—ask your hospice provider to send information to your Part D plan indicating the prescriptions are unrelated to your terminal condition before you get them filled. After receiving this information, your Part D plan must cover the medication.
Note: If you are denied at the pharmacy counter for anti-nausea, anti-anxiety, pain, or laxative medication unrelated to your terminal condition, you should receive a Medicare Prescription Drug Coverage and Your Rights notice. Contact your plan and file an exception request An exception request is a formal written request to your Part D plan asking that it pay for a drug you need. For example, you can file an exception request to pay for a drug that is not on the plan’s list of covered drugs (formulary), or you can ask the plan to lower the cost of an expensive drug on the formulary (see Tiering Exception). . Your plan must contact your hospice provider to confirm that the medication is unrelated to hospice. Be sure to check with your hospice provider that the plan received this information. Afterwards, your plan must provide coverage within three days or within 24 hours if waiting longer could put your health at risk. If you need your medication sooner, you can ask your hospice provider to cover a temporary supply under the hospice benefit.