Medicare Hospice Care Coverage

When you or a loved one becomes a hospice patient, the last thing you want to worry about is insurance coverage. The final stages of a fatal disease can be mentally, emotionally, physically, and financially devastating for patients and their families. Hospice care is available under Medicare Part A to help ease the burden in all four of the above areas.

Hospice coverage is critical when a person reaches the final stages of cancer, kidney disease, or similar life-threatening diseases. The patient may need around-the-clock care during this time, and a hospice team can provide necessary medical care, while also relieving some of the caregiving burden.

What is hospice care?

Hospice care provides medical services for people with terminal conditions, usually in the patient’s home. A Medicare-approved hospice team administers non-curative medical services and support for patients with a terminal illness. This hospice team may include doctors, nurses, and other health professionals who work with you to create a plan of care.

To be covered by Medicare, a hospice patient can only receive palliative treatment. This is treatment to control symptoms and manage pain, not to cure the illness. Hospice care is meant to keep the patient as comfortable as possible. The focus is on maximizing the quality of life for each day the patient has left.

As a Medicare beneficiary, you have the right to stop hospice care at any time if you want to begin curative treatments.

Hospice-care eligibility

Not everyone is eligible for hospice care. Patients must meet the following requirements to be covered by Medicare:

  • You must be eligible for Medicare Part A.
  • You must sign a statement agreeing to hospice care instead of standard Medicare-covered medical care to treat the terminal illness and related health conditions.
  • You must agree to receive palliative care for your condition instead of curative treatment.
  • A hospice physician, along with your regular doctor (if you have one) must determine that you are terminally ill with a life expectancy of six months or less.
  • The hospice care must be received through a Medicare-approved hospice program.

Length of hospice care

Although hospice care is intended for patients who have six months or less to live, you can get hospice care for longer than this if a hospice doctor continues to certify that you’re terminally ill and you still meet eligibility requirements. You need to be recertified by your doctor at the beginning of each benefit period.

Hospice-care benefit periods are for 90- or 60-day periods. If you’re just starting hospice care, you can receive hospice services for two 90-day benefit periods, followed by unlimited 60-day periods. Your benefit period starts on the first day you begin hospice care and ends after 90 or 60 days.

Benefit periods don’t have to be consecutive. Hospice care may be cancelled at any time, and the patient may return to the standard Medicare benefits. For example, if your illness goes into remission or your condition improves, you may not need to continue you hospice care. If you’re eligible again, you may return to hospice care at any time.

What Medicare hospice care covers

Medicare hospice care covers medically necessary services and supplies to care for your terminal condition. As mentioned, any care you receive must be through a Medicare-approved hospice program.

Coverage includes:

  • A one-time hospice consultation with a physician or medical director to discuss your treatment options. You’re covered even if you end up deciding not to get hospice care.
  • Physician services
  • Nursing care
  • Home health and hospice-aide services
  • Homemaker services
  • Medical equipment and supplies
  • Prescription medications for pain and symptom management
  • Physical and occupational therapy
  • Speech-language pathology services
  • Medical social worker services
  • Nutrition counseling
  • Grief counseling for the patient and family
  • Limited respite care for caregivers
  • Limited inpatient care to manage pain and symptoms related to the condition

A hospice doctor and nurse are on call 24 hours a day, seven days a week. Remember that you’re still covered for health care that isn’t related to your terminal illness.

What Medicare hospice care doesn’t cover

There are some limits to hospice coverage. Medicare will not pay for any treatment or medications meant to cure your illness. You’re also not covered for any care that wasn’t set up through your Medicare-approved hospice program. If you aren’t sure whether a service may be covered, check with your hospice team first.

Medicare doesn’t cover housing if you live in an institution, such as a hospice facility or nursing home.

Medicare does cover limited inpatient facility care if it’s for respite care and is arranged through your hospice team.

Costs for hospice care

Hospice patients pay the following costs:

  • Prescription drugs: Maximum of $5 copayment per outpatient prescription medication to manage pain and symptoms.
  • Respite care (inpatient): You’ll pay 5% of the Medicare-approved amount for a maximum five-day stay. Note that you can get respite services more than once as long as it is on an infrequent basis.
  • Room and board: Medicare doesn’t cover costs if you’re staying in a nursing home or hospice facility, unless it’s for short-term respite care.

Medicare covers all other hospice care costs. There’s no deductible for Medicare-covered hospice care.

Hospice care may be worth looking into if you or a family member has been diagnosed with a terminal illness. Understanding all of your treatment options, including hospice, will help you decide the best course of action for you and your family.

For more information, see: Centers for Medicare and Medicaid Services. “Medicare Hospice Benefits.”

To learn about Medicare plans you may be eligible for, you can:

  • Contact the Medicare plan directly.
  • Call 1-800-MEDICARE (1-800-633-4227), TTY users 1-877-486-2048; 24 hours a day, 7 days a week.
  • Contact a licensed insurance agency such as Medicare Consumer Guide’s parent company, eHealth.
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