Hospice is designed to comfort and preserve the quality of life of people who are terminally ill. Hospice care providers are trained to address the spiritual, physical, and emotional needs of terminally ill patients in place of curative treatments. End-of-life care may be covered if a senior with a chronic illness is eligible for Medicare.
Medicare requirements for hospice coverage
- Seniors must have Medicare Part A (hospital coverage)
- The hospice medical director and the senior’s regular physician, if any, must sign off that the senior is terminally ill with a six-month or less life expectancy.
- The senior or their legal guardian must choose palliative care over Medicare-covered benefits to treat their terminal illness. They also need to sign a declaration attesting to this choice.
- A Medicare-approved hospice provider must provide care.
What Hospice Services is Medicare Covered?
Hospice providers provide comprehensive services that are beneficial to both the patient as well as their loved ones. The following services are often included in a patient’s care plan and may be covered by Medicare at least partially.
- Services for doctors
- Nursing care
- Durable medical equipment (e.g. wheelchairs, walkers, etc.)
- Medical supplies (e.g., bandages, catheters)
- Prescription drugs to relieve pain or control symptoms
- Nutritional/dietary counseling
- Homemaker and aid services
- Services for occupational and physical therapy
- Social work services
- Both the patient and their families can receive grief and loss counseling
- Inpatient short-term pain management and symptom management
- Short-term inpatient respite care
- Other Medicare-covered services that the hospice team recommends
Hospice Respite Care Available for Family Caregivers
It is physically and emotionally exhausting to care for someone with a serious illness, particularly if they are nearing the end. Short-term inpatient respite is one of the most useful hospice services Medicare Part A covers. This allows terminally ill patients to continue receiving hospice care in a Medicare-approved hospital, skilled nursing facility, or hospice house. The family caregiver can then rest and recuperate. Inpatient respite can last for up to five days. There may be a small fee for room and board, and a copayment may be required. Respite may be requested by the patient or their family more than once. However, this service is only available on an occasion basis.
What does Medicare not cover for Hospice Patients?
The following items and services are not covered if a Medicare beneficiary is eligible for hospice care.
Hospice care does not cover treatment that is intended to cure terminal illnesses. Patients can withdraw from hospice care at anytime. Patients can also return to treatment anytime provided they meet all eligibility requirements.
Prescription drugs for terminal illnesses.
Medicare hospice benefits cover only drugs that are used to relieve pain or control symptoms.
Any hospice provider who isn’t part of the hospice medical team can provide care.
All care must be provided or arranged by the same hospice medical team. Seniors cannot receive the same hospice care from another provider unless they change their Medicare-approved hospice provider. If the hospice provider has been designated to oversee the patient’s care, they can still see their regular doctor.
Board and room
Medicare doesn’t cover room and board for hospice patients living at home, in nursing homes or in assisted living facilities. Only short-term respite or inpatient stays are covered by Medicare for room and board.
Medicare does not cover transportation by ambulance or care that a patient receives in an ER. These services, unless they are arranged by the hospice medical team or are unrelated to their terminal disease, are not covered by Medicare’s Hospice benefit.
Medicare covers the cost of hospice care
The majority of Medicare beneficiaries do not pay for hospice care. The following out-of-pocket copays might be required for certain services and items:
Each prescription drug and any similar product a patient needs for pain relief or symptom control will cost the patient no more than $5. The hospice provider will call the patient’s Part-D prescription drug plan to ask about coverage if a particular medication is not covered.
Five percent of Medicare-approved costs for inpatient respite.
Medicare negotiates fixed rates (Medicare approved costs) with doctors and suppliers who are willing to accept assignment. If the approved cost for inpatient respite is $100 per day, the patient will be responsible for $5 per day.
Original Medicare (Parts B and A) will cover all the medical needs of a patient with a terminal illness. This applies regardless of whether they are enrolled under a Medicare Advantage (Part C) plan or a Medigap policy (Medicare Supplement Insurance). Seniors in hospice want to keep their Advantage Plan enrolled and continue to pay their premiums for medical benefits and other services that are not related to their terminal illness. Medigap policies often provide additional coverage, such as prescription drugs or respite care, for hospice patients.
How long will Medicare pay for hospice care?
Hospice care is available for patients with less than six months to live. It is difficult to estimate someone’s life expectancy. The Medicare hospice benefit is divided into two 90-day benefit periods, which are followed by an unlimited number 60-day benefit period (if necessary).
As long as the hospice physician certifies that they are still alive, a terminally ill patient may continue to receive covered hospice care. Some people live longer than expected, but retain their terminal status. They can continue receiving hospice care for months or even years.
Before services can start, a patient must be certified that they have at least six months to live. This certification will be renewed at each new benefit period. To recertify their eligibility, a face-to-face meeting must be held with a hospice physician prior to their third benefit period (day 180 in hospice). These meetings must be held no later than 30 days prior to the start of each 60-day benefit period.
Medicare covers most aspects of hospice care at little cost to patients and their families as long as the hospice program is Medicare-approved. (Medicare has an online tool that beneficiaries can use to find and compare hospice programs). More than 1.5 million Medicare beneficiaries received hospice care in 2018, with services provided by more than 4,600 hospice programs nationwide.
Hospice programs offer support and care for terminally ill people. When a Medicare beneficiary enters hospice, the hospice benefits are typically provided via Original Medicare, even if the beneficiary had previously been enrolled in Medicare Advantage.
But as of 2021, CMS is piloting a program that allows Medicare Advantage plans to include hospice benefits. In the first year, 53 Medicare Advantage plans, accounting for 8% of the market, are participating in the pilot program.
Medicare Advantage beneficiaries who are in hospice care (provided by Original Medicare) may need treatment for a condition that is not related to the terminal illness. They can either choose Original Medicare or Medicare Advantage.
To qualify for hospice benefits, a patient must be eligible for Medicare Part A, and a doctor must certify that the patient is terminally ill and has six months or less to live. Medicare-approved programs typically provide care at your home or in a facility near you, such as a nursing or hospital.
Medicare hospice coverage covers a complete range of medical and support services to a life-limiting condition, including medications for pain relief or symptom management, medical, nursing and social services; certain durable equipment and other related services that Medicare doesn’t usually cover.
Hospice care has no deductible and the copays for medications that are covered for pain management or symptom management will not exceed $5. However, if hospice patients need medications that aren’t related to their terminal condition, Part D plans would still cover them with their normal cost-sharing requirements and the patient’s medical provider must notify Part D that the medication is not related. This can be complicated, but it’s important for beneficiaries and their families to understand).
Medicare will also cover respite care, which is a short-term stay at a qualified hospice facility. This allows the caregiver to take a break. It can last for up to five consecutive days.
Medicare doesn’t usually cover board and room in nursing homes. (Here’s a list of services Medicare won’t cover.) In-patient hospice care can be covered in respite or other circumstances if the hospice program determines it is necessary. A hospice patient who receives respite will be charged 5% of the Medicare-approved inpatient cost. Medicare will cover the remaining 95%. Medigap plans can help to cover the out-of-pocket costs associated with hospice care, including respite care.
As long as your hospice doctor or hospice medical director recertifies you are terminally ill, hospice care will continue.