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Choosing Hospice Care (Article 10)
Difficult End-of-Life Decisions Are Best Made When Patients and Loved Ones Understand Their Choices
Hospice care is a choice for TRICARE patients with a terminal illness who are expected to live less than six months. It is an all-inclusive approach that offers a broad variety of supportive care and services to meet patients’ end-of-life needs.In keeping with the principles of family-centered care, the patient’s wishes and those of family members and friends figure prominently in care decisions. All care is focused on “palliating” (lessening the effects of) the terminal condition.

What's Covered
“There are four levels of care within the hospice benefit: routine home care, continuous home care, inpatient respite care and general hospice inpatient care,” says Christine Gavlick, TRICARE health care reimbursement specialist. “One of these levels of care will be in use at all times, and patients often shift among all four, depending on their needs and the needs of family members who are supporting them.”

Care within these levels may include physician services, nursing care, counseling, medical equipment, supplies, medications, medical social services, physical and occupational services, speech and language pathology, and hospice short-term acute patient care related to the terminal illness.

Once patients elect hospice care, their care is managed by the medical director of the hospice and by the interdisciplinary clinical team managing the case, always in consultation with patients and their families. Primary care managers (PCMs) may stay involved and participate in the clinical team, as well as manage any acute needs outside hospice coverage.

Because hospice care emphasizes supportive services, such as pain control and home care, rather than cure-oriented treatment, the benefit allows for custodial care and personal comfort items, which are limited under TRICARE’s main coverage programs. However, services for an unrelated condition or injury, like a broken bone or unrelated diabetes, are still covered as a regular TRICARE benefit.

What's Not Covered
Room and board are not covered under hospice care unless the patient is receiving inpatient level of care. Patients also cannot receive other TRICARE services/benefits (curative treatments related to the terminal illness) unless the hospice care is formally revoked. In other words, no care for the illness is covered by TRICARE unless the hospice provides it or arranges for it.

To formally revoke the hospice election, the beneficiary must submit a signed, dated statement through the hospice provider. This does not alter the beneficiary’s ability to reenter hospice care at a later time.

How to Initiate Hospice Care
Patients considering hospice care should discuss the option with their PCM and family members. As part of their decision-making process, patients may also request a consultation with a hospice facility to ask questions and learn more about how they will be cared for. The patient, his or her PCM, or a family member acting on the patient’s behalf can initiate hospice care, but the hospice will not take action without a doctor’s order.

Patients must complete an “election statement,” which the hospice provides, that indicates their understanding of what hospice care involves. This statement is then filed with the appropriate TRICARE regional contractor. Patients must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) to be eligible for and initiate hospice care.

Hospice care is provided in three benefit periods, each of which requires prior authorization. The patient’s PCM should initiate and obtain the prior authorization from Humana Military, on the patient’s behalf. The first two benefit periods are each 90 days long and begin on the day that a hospice election statement is signed by the beneficiary and a physician’s certificate of terminal illness is signed by both the attending physician and the hospice medical director. The final benefit period comprises an unlimited number of 60-day periods, each of which requires recertification of the terminal illness.

How to Find a Hospice
“The best way to find a TRICARE-authorized hospice is to use your regional contractor’s provider directory,” says Gavlick. “Then contact the hospice and ask about their services, staff and any other questions that will help you make a decision.” Beneficiaries can access the Humana Military provider directory or get more information about hospice care online or by calling 1-800-444-5445.
Alternatives to Hospice Care (Article 11)

TRICARE patients who do not elect hospice care have other options. These options, outlined below, refer to services sought outside of a military treatment facility (MTF) and require prior authorization from Humana Military.

Home Health Care (Covered)
The services covered under TRICARE home health care are the same as those covered under Medicare home health care benefits. Covered services include a maximum of 28 hours per week part time, or 35 hours per week intermittent, skilled nursing care, home health aide services, and physical, speech and occupational therapy. All care must be provided by a participating home health care agency.

Costs per visit:

  • TRICARE Prime active duty family member (ADFM): No copayment
  • TRICARE Prime retirees and others: No copayment if the covered services are rendered through the home health agency under a plan of care. Copayments may apply for services received outside the home health agency prospective payments.

Skilled Nursing Care (Covered)
Skilled nursing care typically is not provided in a nursing home or a patient’s home, but rather in a skilled nursing facility (SNF). Under the SNF benefit, TRICARE covers skilled nursing care and rehabilitative (physical, occupational and speech) therapies, room and board, prescribed drugs, laboratory work, supplies, appliances and medical equipment.

For TRICARE to cover your admission, you must have had a medical condition that was treated in a hospital for at least three consecutive days. Admission to the SNF is covered as long as you are admitted within 30 days of your discharge from the hospital (with some exceptions for medical reasons). Your doctor’s plan of care will need to demonstrate your need for skilled nursing services for Medicare or TRICARE to pay for the SNF care.

Costs per admission:

  • TRICARE Prime active duty family member (ADFM): No copayment
  • TRICARE Prime retirees and others: $11 per day ($25 minimum) copayment

Long-Term Care (Not Covered)
Long-term care (LTC) includes a wide range of support services for patients with a degenerative condition (e.g., Parkinson’s, stroke, etc.), a prolonged illness (cancer) or cognitive disorder (Alzheimer’s). Also known as “custodial care,” LTC primarily involves providing assistance with activities of daily living (walking, personal hygiene, dressing, cooking/feeding, etc.) or supervision of someone who is cognitively impaired.

Long-term care can be provided in many settings, including nursing homes, assisted living facilities, adult day care or a patient’s home. Long-term care is not a Medicare or TRICARE covered benefit. Room, board and the services mentioned as a covered benefit for SNF care (listed above) are not covered under Medicare or TRICARE if determined to be part of long-term care. You need to ask the facility providing care whether or not you are receiving skilled nursing facility care or long-term care. Long-term care costs are your responsibility.

You can purchase LTC insurance through commercial insurance programs or the Federal Long Term Care Insurance Program (FLTCIP).

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Last Reviewed:  December 4, 2007