Hospice Patients Alliance: Consumer Advocacy

PRIVATE INSURANCE CASE MANAGERS:
THERE TO HELP YOU

If you have private insurance which pays for hospice services, you will be assigned an insurance case manager by the insurance company. The job of the insurance case manager is to make sure that you receive all services which the insurance company is paying for. Because the private insurance company is paying for the services, it can request the hospice to provide the services which are reasonable and necessary to help care for your loved one. The per-diem reimbursement plan is used by private insurers as well as Medicare and Medicaid. So, the hospice gets a lump sum for each day the patient is enrolled in the program, and of course, is expected to provide all the services needed. Whether the hospice actually provides all the services needed is another issue.

When your attending physician certifies your loved one as eligible for hospice, the hospice will contact your private insurance company and explain the plan of care to the insurance company's casemanager. The insurance casemanager will state whether or not services are covered. In those cases where hospice is covered, the hospice must provide all the services required by the standards of care in the industry: the Code of Federal Regulations at 42 CFR Part 418. The standards of care do not change whether you have Medicare, Medicaid or private insurance. Because the hospice is licensed, it must meet the standards set down by federal and State law. If you encounter difficulties in resolving a problem with a hospice, either in the qual;ity of care or lack of care, you can speak with your private insurance case manager who can assist you.






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