HMOs and Hospice

MAY 8, 1995 VOLUME 2, NUMBER 44

In recent years HMOs have come to dominate the Medicare field in Arizona. Although marketing sometimes suggests that Medicare recipients “give up” their Medicare benefits to join an HMO, it is important for consumers to realize that the HMO is simply an alternative method of delivering Medicare services.

“Medicare HMOs” (those HMOs providing coverage to Medicare recipients under special arrangements with the federal government) are required to provide the same range of services available to traditional Medicare participants. Of particular significance to many seniors is the requirement that Medicare HMOs provide full hospice benefits.

Medicare Hospice Benefit

Traditional Medicare does not pay for prescription drugs at all and has limited benefits for counseling. In addition, Medicare patients must pay an annual deductible and (in most cases) 20% of the cost of their care. For those enrolled in traditional “fee for service” Medicare plans, these limitations do not apply to hospice benefits.

For the past decade, Medicare has provided full coverage for hospice patients, including prescription drugs, supportive care and counseling (including grief counseling for family members). There is no deductible or copayment for these services. Eligibility does require a diagnosis of terminal illness, with less than approximately six months to live and a desire to “forego curative treatment options.”

The HMO Connection

For those patients who have elected to join a Medicare HMO, the rules may seem to have changed. Since prescription medications may now be partially covered (many plans provide coverage with a modest per-prescription copayment) and the HMO focuses on preventive care, the consumer may be misled into believing that Hospice benefits are treated differently as well.

In fact, Medicare requires that participating HMOs provide full Hospice benefits under the same terms as traditional Medicare coverage. Most HMOs contract with one of the private or non-profit Hospice organizations to provide the required services, and the patient will perceive the transition as having been moved “back on to” Medicare.

Medicare HMOs are discouraged from selecting only the healthiest Medicare beneficiaries. Consequently, they are required to accept nearly all applicants; one of the two major exceptions to this principle is that those already receiving Hospice benefits may not transfer to an HMO. Since the benefits are the same for Hospice patients, however, that should not present any problems for consumers.

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