Provisions Governing Hospice Care

The Plan provides a Hospice Care Program for persons with terminal conditions (a life expectancy of 6 months or less).

Although benefits for hospice care apply to the Comprehensive Benefit lifetime maximum benefit, the expenses are not paid under the regular covered medical expense provisions of the Comprehensive Benefit. A special set of covered expenses applies to hospice care.

Each covered person is entitled to hospice care benefits up to $20,000 during his lifetime. Once a person has received $20,000 in benefits for hospice care, no further benefits for hospice care will be paid. Expenses incurred for any further treatment of his terminal condition will be considered for payment under the regular Comprehensive Benefit provisions, subject to all applicable provisions and limitations governing covered medical expenses.

Eligibility for the Hospice Care Program

  1. A hospice doctor, as well as a person's personal doctor if not a hospice doctor, must certify that a person's medical condition is terminal. The certification must be made no later than two days after the person begins receiving hospice care.
  2. A person must elect to use the Hospice Care Program for any and all palliative care and most direct care of his terminal condition instead of receiving benefits for that care under the regular Comprehensive Benefit provisions.
  3. Once a person's condition is certified as terminal, he can elect to use the Hospice Care Program by filling in an election form stating that he wants to receive hospice care from a specific hospice. Before any hospice care is provided, the election form must be submitted through the hospice from which he will receive the hospice care.

A person can revoke his election of the Hospice Care Program at any time. Benefits for any further care of his terminal condition will be considered for payment only under the regular Comprehensive Benefit provisions. In the future, he can re-elect to be covered under the Hospice Care Program (but the $20,000 lifetime maximum benefit will not start over).

Hospice Care Program Covered Expenses

Only covered expenses incurred for hospice care of a person's terminal condition apply under this Program. Covered expenses include charges made for the following:

  1. Nursing care by an R.N. or L.P.N. and services of homemakers and home health aides (such services may be furnished on a 24-hour basis during a period of crisis or if the care is necessary to maintain the patient at home);
  2. Chaplaincy; and medical social services, counseling services and/or psychological therapy by a social worker or a psychologist;
  3. Physical and occupational therapy and speech language pathology;
  4. Non-prescription drugs used for palliative care, medical supplies, bandages and equipment, and drugs and biologicals used for pain and symptom control; and
  5. Skilled nursing facility short-term inpatient care to provide respite care, palliative care or care in periods of crisis.

Note - Hospice benefits are automatically assigned to the hospice. The hospice will send its bill to the Fund Office and will be paid directly by the Fund Office. You are responsible for paying any expenses not payable by the Plan.

Hospice Care Program Exclusions and Limitations

Charges for the following services and supplies are not covered under the Hospice Care Program:

  1. Services or supplies not provided as core services by the hospice providing the hospice care;
  2. Bereavement counseling (counseling services provided to a terminal person's family) after his death;
  3. Administrative services; child care and/or housekeeping services; or transportation, except in emergency situations; or
  4. Long-term inpatient care; surgical operations or hospital confinements due to medical complications of the terminal condition; or treatment of any injury or sickness other than the person's terminal condition. (Covered expenses incurred for these services and supplies are considered for payment under the regular Comprehensive Benefit provisions and limitations governing covered medical expenses.)

Contact the Fund Office before seeking hospice care for any member of your family.