Hospice is a kind of care for people whose illness can no longer be cured. The goal changes from treating the disease to keeping the person comfortable: managing pain and symptoms, and caring for emotional and spiritual needs too. A hospice team does this work, mostly where the person lives, and it supports the family too.
For most people in the US, Medicare pays for it through Part A. Here's who qualifies, what's covered, what isn't, and what happens if things change.
Who qualifies for hospice under Medicare?
Medicare lists three conditions, on top of having Part A:
- The hospice doctor and the patient's regular doctor (if there is one) certify that the patient is terminally ill. Federal rules define that as a life expectancy of 6 months or less if the illness runs its normal course.
- The patient accepts comfort care (also called palliative care) instead of care to cure the illness.
- The patient signs a statement choosing hospice instead of other Medicare-covered treatment for the terminal illness and related conditions.
If the patient is too ill to sign, federal rules let their representative sign instead.
Medicare says only those two doctors, the hospice doctor and the regular doctor if the patient has one, can certify that a patient is terminally ill. A patient with no regular doctor can be certified by the hospice doctor alone.
The statement the patient signs is called the hospice election statement. Medicare.gov says it names the hospice giving care, the date services start, and the doctor the patient chooses as their attending doctor. It has to be completed before any hospice services begin.
Before choosing, a patient can have a one-time consultation with a hospice medical director or hospice doctor to talk through options and symptom care. The patient can have it even if they decide against hospice.
Medicare only pays for hospice from a Medicare-approved provider. You can search hospices by state and compare them with Medicare's hospice ratings.
What the hospice benefit covers
Once a patient chooses hospice, Medicare.gov says the benefit should cover everything they need for the terminal illness. The plan of care can include:
- Doctor services and nursing care
- Medical equipment, like wheelchairs or walkers, and supplies, like bandages and catheters
- Prescription drugs for pain and symptom control
- Hospice aide and homemaker services
- Physical and occupational therapy, and speech-language pathology
- Social worker services and dietary counseling
- Grief and loss counseling for the patient and family
- Short-term inpatient care for pain and symptoms, and short-term respite care
A hospice nurse and doctor are on call 24 hours a day, 7 days a week. The patient can keep their regular doctor, nurse practitioner or physician assistant as the attending medical professional.
If you pay out of pocket for something the doctor ordered because the hospice refused to provide it, Medicare's booklet says you can file an appeal. Your State Health Insurance Assistance Program (SHIP) can help with that.
The four levels of hospice care
Every Medicare-certified hospice has to offer four levels of care.
| Level | What it's for | Where it usually happens |
|---|---|---|
| Routine home care | The most common level. The patient's symptoms are under control. | Where the patient lives |
| Continuous home care | A short crisis when symptoms are out of control. Mostly nursing care, for as much as 24 hours a day, so the patient can stay at home. | Where the patient lives |
| General inpatient care | Short-term care for pain or symptoms that can't be managed at home. | A hospital, skilled nursing facility or inpatient hospice facility |
| Inpatient respite care | A break for the family caregiver. The patient can stay up to 5 days at a time, on an occasional basis. | A nursing home, inpatient hospice facility or hospital |
A few details from CMS's coverage manual help explain the table:
- Continuous home care is only for brief periods of crisis. The hospice must give at least 8 hours of care in a day, and more than half of those hours must be nursing care. When fewer than 8 hours are needed, it counts as routine home care. It can also be given to a patient living in a long-term care facility, but not in a hospital, skilled nursing facility or hospice inpatient unit.
- General inpatient care is for pain or symptoms that can't be managed in any other setting. The hospice arranges it.
- Respite care is only for patients cared for at home. It isn't available to a patient who already lives in a facility like a nursing home. Medicare pays for up to 5 days in a row each time. If a stay goes past 5 days, the patient pays room and board from the sixth day.
What Medicare won't cover once hospice starts
The benefit doesn't cover:
- Treatment intended to cure the terminal illness and related conditions.
- Prescription drugs to cure the illness, as opposed to drugs for comfort.
- Care for the terminal illness that the chosen hospice didn't give or arrange.
- Room and board at home or in a nursing home. Short-term inpatient or respite stays the hospice arranges are the exception.
- Emergency room visits, hospital stays and ambulance rides, unless the hospice arranges them or they're unrelated to the terminal illness.
Medicare suggests calling the hospice team before getting any of these, or you might pay the full cost.
Room and board is worth asking about early. Medicare.gov says that if the patient lives in a facility, like a nursing home, and chooses hospice, they may have to pay for room and board there. The hospice benefit pays for hospice care, not the facility's charge for room and board.
The same goes for hospital care. If the patient needs inpatient care for the terminal illness, the hospice must make the arrangements. Medicare's booklet says that if the patient goes to the hospital without the hospice arranging it, they might be responsible for the entire cost.
Drugs that aren't for the terminal illness aren't part of the hospice benefit. Medicare's booklet says they may be covered by Medicare drug coverage (Part D), with that plan's usual copay.
Health problems unrelated to the terminal illness are still covered by Original Medicare, with the usual deductibles and coinsurance. You can ask the hospice for a written list of what it considers unrelated, with its reasons; Medicare.gov says it must arrive within 3 to 5 days.
What you may pay
There's no deductible for hospice care. According to Medicare's hospice booklet, the patient pays:
- Their usual monthly Part A and Part B premiums.
- A copayment of up to $5 per prescription for outpatient drugs for pain and symptoms.
- 5% of the Medicare-approved amount for inpatient respite care. For example, if Medicare approves $100 a day, the patient pays $5 a day. This copay can't be more than the inpatient hospital deductible for the year.
The booklet adds that the amount you pay for respite care can change each year. The hospice also has to tell you if any drug or service isn't covered, why, and whether you'll have to pay for it.
Federal rules say a hospice can't cut care for a Medicare or Medicaid patient who can't pay.
Benefit periods, changing hospices, and stopping
Hospice is given in benefit periods: two 90-day periods, then an unlimited number of 60-day periods. At the start of each period after the first, a hospice doctor has to recertify that the patient is terminally ill.
A benefit period starts the day hospice care begins. The patient doesn't have to choose hospice again for each new period; the recertification carries it forward. Medicare's booklet says that a patient who lives longer than 6 months can keep getting hospice care as long as the hospice medical director or another hospice doctor recertifies that they're terminally ill.
Before the third benefit period, which starts after the first 180 days, and before every period after that, a hospice doctor or hospice nurse practitioner must see the patient in person. This is called the face-to-face encounter. CMS's manual says it has to happen no more than 30 days before the new period starts, and the findings go into the recertification.
The patient can change to a different hospice once in each benefit period. CMS treats this as a transfer, not as stopping hospice. The patient signs a statement for both the old and the new hospice with the name of each and the date the change takes effect. The benefit period dates stay the same.
The patient can also stop hospice at any time, for example if their health improves. They sign a form with the date care will end, and their regular Medicare coverage starts again. No one should ask them to sign stopping forms they didn't ask for. If they're eligible later, they can go back to hospice.
A few more points from CMS on stopping. It has to be done in writing; saying it out loud isn't enough. The end date can't be earlier than the day the form is signed. Any days left in that benefit period are given up. There's no waiting period to come back, though: a patient who still qualifies can choose hospice again right away.
Stopping is the patient's choice: CMS says a hospice can't revoke it for them, and can't routinely discharge a patient because care is costly or inconvenient.
If the hospice decides the patient no longer qualifies and the family disagrees, the patient has the right to a fast review by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The hospice should give a notice explaining how.
Medicare Advantage, Medigap, Medicaid and private insurance
With a Medicare Advantage Plan, Original Medicare pays for hospice even if the patient stays in the plan, which can keep covering extra benefits and unrelated care while premiums are paid.
Medicare's booklet says a Medigap policy covers hospice costs for drugs and respite care.
For Medicaid, hospice is an optional benefit, so coverage depends on the state. Where it's offered, the rules are similar: the patient elects hospice, waives curative treatment for the terminal condition, and can revoke the election at any time. Medicaid and CHIP patients under 21 can get curative treatment and hospice at the same time.
For private insurance, Medicare's checklist for choosing a hospice suggests asking whether the hospice accepts the patient's insurance and which services will be covered.
Frequently asked questions
Does choosing hospice mean stopping all treatment?
It means stopping Medicare-paid treatment meant to cure the terminal illness. Comfort care continues, other health problems are still covered, and the patient can leave hospice to try curative treatment.
What if the patient lives longer than 6 months?
Hospice can continue. After the two 90-day periods, Medicare covers an unlimited number of 60-day periods, as long as a hospice doctor recertifies the patient for each period, with an in-person visit from the third period on. Some patients also improve and leave hospice, and can come back later if they qualify again.
What happens when someone dies at home under hospice care?
Call the hospice. Its nurse is on call around the clock and can explain what happens next. Our guide to the first 48 hours walks through the steps after a death.
Does hospice support the family after the death?
Yes. Federal rules require hospices to offer bereavement services to the family for up to a year after the patient dies.
Where is hospice care given?
Usually where the patient lives: a house, an assisted living facility or a nursing home. Short-term inpatient care happens in a hospice facility, hospital or skilled nursing facility.
Sources
- Medicare: Hospice care coverage
- Medicare: Medicare Hospice Benefits (CMS Product No. 02154)
- Medicare Care Compare: Hospice levels of care
- Medicare Care Compare: Suggested questions to ask when choosing a hospice
- CMS: Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services
- eCFR: 42 CFR Part 418, Hospice care
- Medicaid.gov: Hospice benefits