Does Medicare Cover Hospice Care?
Medicare covers hospice care for individuals who are terminally ill and have Medicare Part A coverage, also called hospital insurance. Hospice-eligible patients must meet essential prerequisites and receive their hospice care from a Medicare-approved provider.
Medicare’s hospice coverage includes doctor and nursing care, medications, medical equipment, therapy, counseling, and other services necessary to treat–not cure–the patient’s terminal illness. In most cases, patients receive hospice care in their home or that of a loved one, but short-term inpatient care is also covered under certain circumstances.
Patients who use their hospice benefit cannot use Medicare to cover other treatments for their terminal condition.
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A Small Relief In Difficult Times — Medicare Guidelines for Hospice Care
Hospice care serves people who have incurable terminal illnesses and those who choose not to pursue curative care for their illnesses, with teams that include nurses, doctors, counselors, social workers, and pharmacists, all on-call 24/7. These providers focus on the patient’s quality of life, also extending support to family members.
This kind of care is common among Medicare beneficiaries. In 2020, over 47% of Medicare decedents—amounting to 1.72 million people—used their hospice benefit. The most frequent principal diagnosis among these beneficiaries was dementia, including Alzheimer’s disease.
What Hospice Services Does Original Medicare Cover?
Original Medicare is a two-part health plan that covers hospital insurance (Medicare Part A), including hospice, and medical insurance (Medicare Part B). If you become eligible for your hospice benefit and choose to use it, Original Medicare will cover all care related to your terminal illness, which may include the following:
- Doctor and nursing services
- Home care aide services
- In-patient care to manage pain and other symptoms
- Loss and grief counseling
- Medical supplies and equipment
- Physical and occupational therapy
- Prescription medications
- Respite care
- Social worker services
- Other necessary covered services recommended by your hospice team to manage your illness
Your hospice benefit lets you stay in your or a family member’s home while you receive care, or you may choose to stay in a hospice facility if your provider determines that inpatient care is necessary.
Using your hospice benefit means forgoing Medicare coverage for the treatment of your terminal illness. However, your plan might still cover services for conditions that are unrelated to your terminal illness. For example, a patient who receives hospice care for Alzheimer’s disease may still pursue Medicare-covered treatment for conditions that are not related to their dementia.
If you’re unsure, ask your hospice provider for a list of drugs and services that are not related to your terminal illness.
Medicare Regulations for Hospice Eligibility
To qualify for Medicare-covered hospice care, you must meet all of the following eligibility standards:
- Your regular doctor (if applicable) and hospice doctor determine that you are terminally ill with 6 months or less left to live.
- Instead of pursuing care intended to cure your illness, you accept comfort care, also known as palliative care.
- You must sign documentation verifying your choice of hospice care for your terminal illness and any related conditions.
Before electing to use your hospice benefit, you can see a hospice medical director or doctor for a one-time consultation to explore your options for care and symptom management.
How Long Does Coverage Last?
To qualify for hospice coverage, you need a life expectancy of 6 months or less, but once you’ve chosen to use your hospice benefit, you can receive care for longer than 6 months if necessary.
As a hospice patient, you start with two 90-day benefit periods; after that, you can get as many 60-day benefit periods as needed. At the start of each 60-day benefit period, a hospice doctor must recertify you as terminally ill.
What Does Medicare Not Cover?
Because hospice is intended to provide comfort and care to patients with terminal illnesses, the hospice benefit doesn’t cover treatment to cure your terminal illness, and you must receive hospice services from a Medicare-approved provider. Under the Medicare guidelines for hospice, the following services are also not covered:
- Ambulance transportation
- Care from a provider who is not part of your hospice medical team
- Hospital inpatient or outpatient care
- Prescription medications not for your terminal condition
- Room and board during your hospice care
If your hospice team arranges ambulance transportation or for you to receive inpatient or outpatient hospital care, your benefit can cover it. Your Medicare plan may also cover these services if they are not related to your terminal illness.
The Cost of Hospice Care With Medicare
With Medicare coverage, you should pay nothing for hospice care. But some medications and other types of care may incur costs. Here’s what you can expect to pay as a Medicare-covered hospice patient:
- A $5 copay per outpatient drug prescription
- The monthly premiums for your Medicare A ($0-$506) and Medicare B ($164.90) plans
For inpatient respite care, you’ll pay 5% of the Medicare-approved amount, which is the maximum amount Original Medicare will pay for care. If the Medicare-approved amount doesn’t cover the cost, you’ll be responsible for the difference plus that 5%. Respite care coverage lasts 5 days, and adult day health care costs around $70 to $80 per day.
No deductible applies to your Medicare hospice benefit.
How Do Other Medicare Options Cover Hospice Services?
Medicare Advantage (MA) plans are HMOs and PPOs provided by Medicare-approved private companies. Thanks to the MA Value-Based Insurance Design (VBID) Model, qualifying MA enrollees can receive full hospice coverage.
Medicare Advantage and the VBID Model Hospice Benefit
In 2023, about 9.3 million people enrolled in Medicare Advantage plans will be able to access health care benefits—including hospice coverage—via the MA VBID Model.
The VBID Model is intended to improve the quality of care, lower costs, and expand options for MA enrollees. To achieve these goals, the VBID Model is testing various payment and service approaches, including Medicare hospice benefit offerings, for people with Medicare Advantage plans.
Previously, MA plans largely excluded hospice from their coverage, splitting responsibility for hospice care between Medicare Advantage and Fee-for-Service Medicare. As a result, hospice coverage was complicated and fragmented for MA participants. Now, VBID’s hospice component aims to enable a smooth transition to hospice care for MA enrollees.
What This Means For You
This means if you have a Medicare Advantage plan, you can still receive hospice care coverage through Original Medicare. If you qualify for and want to start hospice care, your Medicare Advantage plan must help you find a local Medicare-approved hospice provider. Once you begin hospice care, Original Medicare coverage kicks in.
You can keep your Medicare Advantage plan for the duration of your hospice care as long as you keep paying your plan’s premiums. Medicare Advantage will still cover services unrelated to your terminal illness while you’re in hospice care.
Medicare Supplement, or Medigap
A Medigap policy might come in handy when you elect your hospice benefit. Medigap plans, also called Medicare supplement plans, pay for the out-of-pocket costs not covered by Original Medicare.
According to the Medicare guidelines for hospice, patients are still liable for prescription drug copays ($5 per prescription) and a portion of the cost of respite care (at least 5%). A supplement plan can help cover those costs, plus health care expenses that aren’t related to the patient’s terminal illness.
How to Get Hospice Care with Medicare
If your hospice or primary care doctor has certified that you qualify for hospice, the next steps are yours to take. Entering hospice is a heavy decision. Support from a hospice team can help you navigate this time, and they often include therapists and counselors who can work with you and your loved ones. Here’s what you can do to move forward with support from a hospice team.
- Find a Medicare-certified hospice provider.
- Create a care plan with your hospice team.
- Apply for hospice services with Medicare.
The next sections break down the process further.
1. Find a Medicare-certified hospice provider
Medicare hospice requirements state that patients receive care from Medicare-approved providers. Here are your options for finding one:
- Ask your doctor to help, or your plan if you have Medicare Advantage.
- Talk to your state’s hospice organization. Find its number at Medicare.gov/talk-to-someone or by calling 1-800-633-4227.
- Visit Medicare.gov/care-compare to browse providers near you.
When evaluating potential providers, ask how each would approach your individualized care plan, including interactions with your family members. The National Hospice and Palliative Care Organization (NHPCO) provides a worksheet to help patients and their loved ones select a suitable hospice.
Medicare Hospice Eligibility Criteria
Medicare-approved hospice providers must consult with the patient’s attending physician (if available) to write a detailed plan of care for the patient. Other Medicare hospice eligibility criteria include:
- The designation of an interdisciplinary team involving at least a hospice-employed or contracted medical doctor, a registered nurse, a social worker, and a counselor
- The provision of training and education to the patient and their primary caregivers regarding their responsibilities in the patient’s written plan of care
- An established plan of communication to ensure the plan of care is carried out
Medicare’s regulations for hospice service are considered an industry standard regardless of insurance. But if you pursue care from a non-Medicare-approved provider, your services will not be covered by Medicare, and care standards may not be enforceable.
2. Create a care plan with your hospice team
Every Medicare-approved hospice team must create an individualized plan of care for each patient. This plan details the services required to meet the needs of the patient and their family, including:
- Strategies for pain and symptom management
- A statement describing the scope of necessary services and their frequency
- Anticipated outcomes of the plan of care
- Medications and treatments
- Medical equipment and supplies
- Documentation of the patient’s or their representative’s understanding of, involvement with, and consent to the plan of care
3. Apply for hospice services with Medicare
If you think hospice care would be the right next step for yourself or a loved one, there’s no need to wait for a physician to bring it up. Any patient or family member can initiate the process of getting hospice care as long as the patient is eligible.
If you want to pursue hospice care for yourself, bring it up with your physician. If they determine you are eligible, you must sign a statement declaring that you are forgoing curative care and accepting hospice care. This means you agree to not seek services and treatments aimed at curing your terminal illness, such as chemotherapy. However, Medicare will still cover care unrelated to your illness. For example, Medicare will still cover a doctor’s visit to address a joint sprain if it is unrelated to your illness.
Once you’ve been certified terminally ill, met Medicare’s hospice qualifications, and submitted your consent form and other necessary documents, you can proceed with hospice care.
For a Family Member
If you believe a loved one would benefit from hospice care, you can help get the ball rolling. If your loved one is willing and able, start a conversation with them to discuss the option of hospice and the process of pursuing care. Next, you can continue the conversation with your loved one’s healthcare provider.
If your loved one cannot elect hospice for themselves and you believe they would benefit from the care, someone legally authorized to act on their behalf must do so.
What You Need to Know About Hospice Care Beyond Medicare
Beginning hospice care not only involves a series of important decisions such as choosing a high-quality provider, making end-of-life health care plans, and finding support and resources for the patient and their family, but it has a profound emotional impact on everyone involved. Thankfully, the hospice care industry takes this into consideration and places a heavy emphasis on the importance of quality care.
Your Quality of Care Matters
NHPCO publishes the following standards of practice for hospice programs:
- Care and services center around the patient and their family or caregiver
- Clinical safety and excellence
- Inclusion and access to all people regardless of age, disability, ethnicity, gender, religion, and other characteristics
- Collaborative, communicative, and ethical practices
- The interdisciplinary workforce receives professional development, training, and support
- Compliance with applicable regulations and laws, including processes to prevent abuse and fraud
- Qualified, diverse leaders
- Use of measurable performance data to ensure quality and ongoing improvement
If you’re concerned about your or a loved one’s quality of hospice care, you can file a complaint directly with the hospice provider. If doing so is insufficient or you’d prefer an alternative option, you can file a complaint with your State Survey Agency or your state’s Beneficiary and Family-Centered Care Quality Improvement Organization.
Create an Advance Directive and Other Important Documents
An advance directive contains a living will and a healthcare proxy. In these documents, you state your preferences for health care and appoint someone to make medical decisions on your behalf if and when you become unable to do so on your own.
For your living will to take effect, two physicians must certify the following:
- You can no longer make decisions regarding your health care.
- You’ve entered the medical condition specified in your state’s living will law (e.g., permanent unconsciousness).
- Any other stipulations your state requires.
Other important documents to think about during hospice care include a physician’s order for life-sustaining treatment or not to resuscitate and a power of attorney.
How to End Hospice Care
You reserve the right to stop hospice care at any point, such as if your health improves, your terminal illness goes into remission, or you are unsatisfied with your care. To end hospice care, talk with your provider, who will have you sign a form noting the date that your care will stop. Only you can choose to stop your hospice care; note that you shouldn’t sign any forms until the day you intend to end your care.
If you have a Medicare Advantage plan and paid your premiums while under hospice care, you can continue MA coverage after stopping hospice care. Otherwise, you can continue under Original Medicare after ending your care.
As long as you are eligible, you can return to hospice care at any time.
Education and Support Resources for Loved Ones
If you are caring for or supporting a loved one in hospice, it’s important to continue to care for yourself and your needs. The end of life is often a difficult time for everyone involved, and your loved one’s hospice team should provide counseling and other services to family members. You can also check with local hospice organizations for support groups and other helpful resources.
Friends and family members of people in the hospice system can visit the resources below to connect with support groups and find useful advice and caregiving information:
- ALS Association: Runs local support groups for ALS patients and their family members
- Alzheimer’s Association: Provides tips and resources for caregivers
- American Cancer Society: Offers support and online communities for anyone whose lives have been touched by cancer
- CaringBridge: Aims to build community for anyone going through a health journey, including loved ones
- CaringInfo: Produces informative guides and resources for those involved in the end-of-life process (in connection with NHPCO)
- Grief Center: Hosts a community of people experiencing grief, major loss, and death
- Today’s Caregiver: Provides information and support for family members and professional caregivers
Putting It All Together
Entering hospice care is a complex decision for patients and their loved ones, but many people find empowerment in the process. Medicare coverage ensures a high quality of care and helps keep hospice affordable and accessible.
If you or a loved one is at the end of life and may benefit from hospice care, don’t hesitate to discuss it with a physician to explore potential next steps.