Medicare Coverage for Hospice Care

Q. My father is terminally ill, and we are considering hospice care for his remaining weeks or months. I’ve heard that Medicare has a hospice benefit. Can you explain how it works and how much it would cost?

Medicare has covered hospice care since 1983. It’s one of the most generous benefits that Medicare provides—at little cost to terminally ill patients or their caregivers. Patients who select hospice care are offered a full range of medical and support services, most often in their own homes. It also allows them to be cared for temporarily in an inpatient facility, such as a hospital or nursing home, if their regular caregivers need a break.

What is hospice care?

There may come a time when a treatment intended to cure a serious illness stops working effectively or is more than the patient can bear. Hospice care offers an alternative in the last days or months of life. It focuses not on trying to cure the disease but on providing as much comfort as possible—medical, social, emotional and spiritual—during the time left.

Who is eligible for the Medicare hospice benefit?

To qualify, you must meet all of these conditions:

• You must choose to receive hospice care and give up treatments intended to cure your terminal illness;

• Your doctor and the medical director of a hospice program must certify that you probably have less than six months to live, according to their best clinical judgment;

• You must have Medicare Part A hospital insurance;

• You must enroll in a hospice program that Medicare has approved.

What does the hospice benefit cover?

Medicare covers a one-time consultation with a hospice doctor or medical director to discuss your options for care under the hospice benefit. Medicare pays for this consultation whether or not you ultimately choose hospice care. If you decide to go ahead, it will cover the costs of a trained team of medical and support staff to help you and your family, including the following:

• Doctor services and nursing care, plus round-the-clock, on-call support.

• Medical equipment and supplies.

• Medications to control symptoms and pain.

• Homemaker and home health aide services.

• Physical, occupational or speech therapy.

• Social worker services and dietary counseling.

• Short-term care in a hospital or other facility for medical reasons, as recommended and arranged by your hospice team.

• Short-term respite care in a hospital, nursing home or other type of long-term care facility for up to five days at a time if your caregiver needs a rest.

• Support for your caregiver and family members and, if requested, coaching on how best to help meet your needs.

• Grief and loss counseling for you and your family.

What does the hospice benefit not cover?

When considering hospice care, bear in mind that Medicare will not cover:

The cost of treatment (including prescription drugs) intended to cure your terminal illness. You cannot have the hospice benefit and also use your regular Medicare coverage to pay for this treatment. But Medicare will still cover the costs of treating other medical conditions (including hospital stays) not connected to your terminal illness.

Room and board. Typically, hospice care is provided to people living in their own homes. It’s also available to those who live in nursing homes or a hospice residential facility, but Medicare does not pay anything toward the costs of room and board. The exception is short-term inpatient and respite care, as noted above.

What does hospice care cost?

Medicare pays the hospice program a daily fee that covers almost all of your costs. You pay the following:

No more than $5 per prescription for each medication used to control symptoms and provide pain relief for your terminal illness.

A copayment for inpatient respite care, amounting to 5 percent of the Medicare-approved daily rate. (For example, if Medicare pays $200 a day, your share would be $10 a day.)

Is the decision to receive hospice care irrevocable?

No. You can change your mind and stop hospice care for any reason at any time. Similarly, if you stop hospice care and later want to return to it, you can do that, too. When not receiving hospice care, you will have the same kind of Medicare coverage that you had before.

How long can you get Medicare coverage for hospice care?

The Medicare hospice benefit continues as long your doctor and a hospice doctor continue to certify that you are terminally ill, even if you live longer than six months. If your health improves and the doctors decide you no longer need hospice care, the benefit ends—although if you don’t agree with their decision, you have the right to appeal it. If your health deteriorates again, and the doctors recertify that your illness is terminal, the benefit can begin again.

What if you are in a Medicare Advantage health plan or have medigap insurance?

Hospice care is covered regardless of whether you’re enrolled in a Medicare health plan (such as an HMO or PPO) or in the traditional Medicare program. If you have private medigap supplemental insurance, it will still cover health care costs that are not related to your terminal illness, depending on the terms of your policy.

For more information on hospice care and how to find a Medicare-approved hospice program, go to:

“Medicare Hospice Benefits” (Medicare publication).

The National Hospice and Palliative Care Organization.

National Association for Home Care & Hospice.

Patricia Barry is a senior editor at the AARP Bulletin.