May 2nd 2024
By Ari Parker
Hospice services are free for Medicare beneficiaries who qualify, but beneficiaries pay certain copays and coinsurances. Learn more in this article.
When a loved one is approaching the end of life, families need hospice care services to make their family member comfortable.
But is hospice covered by Medicare? In short, yes. Medicare pays for hospice care, which can be provided either in a facility or at the patient's home. The choice between at home or in a facility ensures the most comfort and support to those with terminal illnesses and their families.
Understanding Medicare's hospice coverage will help you plan for what's covered and what isn't. Here’s what you need to know.
Medicare covers hospice care when your loved one has a life expectancy of six months or less. This care focuses on providing peace, dignity, and quality of life rather than curative treatments for the illness.
While the hospice care team can provide services in your family member's home, Medicare doesn't often cover 24-hour continuous care.
Most hospice services are paid for in full by Medicare, but there are some costs to consider. Out-of-pocket costs for hospice care include a 5% coinsurance for inpatient respite care and a copay of $5 for each prescription drug used to help manage symptoms.
Once hospice care begins, Medicare won't pay for any treatments intended for curing the terminal condition. The focus shifts entirely to comfort care and supporting both the patient and their family members through this difficult time.
Hospice care is specialized care for people nearing the end of life. Rather than providing treatment intended to cure, hospice care focuses on making a person comfortable and content. It does not try to prolong or end life.
Hospice care typically includes:
Medical care and medical supplies
Pain and symptom management
Emotional and spiritual support
Support and education for families
Grief counseling for families
A physician must determine that a patient is terminally ill and near death to recommend hospice services. Medicare covers two initial 90-day benefit periods, totaling 180 days. If the patient lives beyond six months, their doctor can recertify them for unlimited 60-day periods until either they pass or their condition improves. If they improve and no longer meet hospice criteria, they can stop hospice care and return to regular medical treatment.
People often confuse hospice care with palliative care or comfort care. While all these types of care focus on comfort, palliative care and comfort care services aren't limited to end-of-life situations. People receiving these services aren't necessarily terminally ill.
Medicare Part A covers hospice care if you meet certain eligibility requirements related to terminal illnesses. You can receive this care in your home, a nursing home, or other facilities, but you must use a Medicare-certified hospice agency. While Medicare covers the care itself, it typically won't pay for room and board in a nursing home or facility.
Your hospice benefit usually covers all necessary medical services during this time. Medicare will also continue to cover medical care needed for health problems unrelated to your terminal illness.
Medicare-approved hospices offer four different levels of care based on hospice patients' needs.
Routine home care: Routine home care is the most common level of care, and with it, most care happens at home. The hospice team makes regular visits to provide medical care, manage symptoms, and support both patients and family caregivers. This includes nursing services, medical equipment, and help with daily care.
Continuous home care: During severe symptom flare-ups, Medicare covers short-term continuous care at home. This provides 8-24 hours of nursing care to manage acute symptoms during medical crises.
General inpatient care: If symptoms become too difficult to manage at home, Medicare covers care in a Medicare-approved facility, such as a hospital or hospice inpatient unit, until you can return home.
Respite care: To support family caregivers, Medicare covers up to 5 consecutive days of inpatient care. While you can use respite care multiple times, it's not meant for frequent use.
To qualify for Medicare hospice coverage, you must meet two conditions:
Both a hospice doctor and your regular doctor must confirm you have a terminal condition with a life expectancy of six months or less.
You must document that you're choosing hospice care instead of Medicare-covered treatments aimed at curing your condition.
Medicare provides comprehensive coverage for hospice care services. A team of healthcare professionals will create a plan of care tailored to your condition and the patient's needs.
Medicare covers these hospice services:
Doctor visits to ensure specialized end-of-life care
Skilled nursing care for symptom management
Medical equipment and supplies for pain relief
Home health care aides and homemaker services
Physical therapy, occupational therapy, and speech-language pathology
Dietary counseling, when needed
Social workers and chaplains for educational, bereavement, emotional, spiritual support, and grief counseling for beneficiaries and their families
Short-term inpatient respite care to give your family caregiver time to rest
Additional services recommended by your hospice team for comfort
Once your hospice benefit begins, Medicare won't pay for:
Treatment or prescription drugs meant to cure your terminal condition
Emergency room visits, ambulance transportation, and hospital care (unless it’s for services unrelated to your terminal illness)
Care from a hospice agency other than your chosen one
Room and board
Before receiving any services, discuss potential costs with your hospice team to understand what you might need to pay.
Medicare's hospice benefit doesn't cover continuous 24-hour care in most cases. However, in specific situations, Medicare will approve continuous home care when patients have acute symptoms requiring frequent monitoring.
This continuous care can typically last up to 21 days and requires that you:
Have Medicare Part A
Have a terminal illness with a life expectancy of six months or less
Need frequent monitoring due to acute symptoms
If your loved one needs round-the-clock care at home, you have three options:
Hire a private caregiver (though this can be costly)
Use Medicare's respite care benefit, which covers up to five days in a care facility to give family caregivers a break
Consider inpatient hospice care at a skilled nursing facility, where staff are available 24/7.
Talk with your doctor and hospice provider to determine the best option for your situation.
Once you start hospice care, Original Medicare covers everything related to your terminal illness, even if you remain enrolled in a Medicare Advantage (Part C) plan. In fact, coverage for hospice care can’t be offered by Medicare Advantage plans.
This means any out-of-pocket costs, copays, coinsurance, and deductibles for hospice care are determined by Original Medicare's rules, not the specific terms of the Medicare Advantage plan.
Medicare covers most hospice care costs, but you'll owe some costs for two main services and treatments: prescription drugs and inpatient respite care.:
Prescription drugs:
You'll pay up to a $5 copay for each outpatient drug used to manage pain and symptoms.
If your hospice benefit doesn't cover a prescription (which is rare), your hospice provider will work with your Part D insurance to check coverage and coordinate payment.
Inpatient respite care:
You may pay 5% of the cost of care (not exceeding the Part A deductible).
Medicare covers up to 5 consecutive days of inpatient respite care to give caregivers a break.
You can use this benefit multiple times, but not frequently.
Your hospice provider coordinates all respite care arrangements.
Rest assured that Medicare covers most hospice costs, letting you focus on the comfort of yourself and your loved ones during this difficult time.
Medicaid typically covers hospice care, including nursing care, physician visits, counseling, and short-term inpatient care. Coverage details and costs vary by state. Contact your state's Medicaid agency to learn about specific benefits in your area. To understand more about the differences between Medicare and Medicaid coverage, see our guide to Medicare vs. Medicaid.
Have more questions about what Medicare does and doesn’t cover when it comes to hospice care? Speak with one of our independent Medicare Advisors, who are eager to help you understand your coverage and how to get the most out of Medicare. Get in touch by calling us at (855) 900-2427 or picking a time to chat.
