The Hospice Guide
The Medicare Hospice Benefit
What the Medicare hospice benefit covers, what it does not, costs such as the $5 drug copay, benefit periods and your rights.
If your loved one qualifies, Medicare Part A covers hospice care from a Medicare-approved hospice with almost no out-of-pocket cost. The most you would normally pay is a copayment of up to $5 per prescription for symptom-control drugs and a small share of the cost of respite care.
Who qualifies
The person must have Medicare Part A, be certified by a doctor as terminally ill with a life expectancy of six months or less, choose comfort care instead of curative treatment for that illness, and sign a hospice election statement. Read the full details in who qualifies for hospice.
What Medicare covers
Once hospice starts, Medicare covers everything in the hospice plan of care that relates to the terminal illness and related conditions, including:
- Doctor and nursing services
- Hospice aide and homemaker services
- Medical equipment, such as a hospital bed, wheelchair, walker or oxygen
- Medical supplies, such as bandages and catheters
- Drugs for pain and symptom management
- Physical, occupational and speech therapy when needed for comfort
- Social work services and dietary counseling
- Spiritual and grief counseling for the patient and family
- Short-term inpatient care for pain or symptoms that cannot be managed at home
- Short-term respite care, so the family caregiver can rest
These services are delivered through the four levels of hospice care.
What Medicare does not cover
- Treatment meant to cure the terminal illness or related conditions. To get that kind of treatment, the person can stop hospice at any time.
- Drugs meant to cure the illness (as opposed to drugs for comfort).
- Care from providers the hospice did not arrange for the terminal illness. Your loved one can still see their regular doctor if they choose them as the attending doctor.
- Room and board. Medicare does not pay for living costs at home, in a nursing home or in assisted living. Short-term inpatient and respite stays arranged by the hospice are covered.
- Hospital or ambulance care related to the terminal illness that the hospice team did not arrange.
Medicare still covers health problems that are not related to the terminal illness, such as a broken arm, under regular Medicare rules with the usual deductibles and copays.
What you may pay
- Hospice care itself: $0.
- Outpatient drugs for pain and symptoms: up to $5 per prescription.
- Inpatient respite care: 5% of the Medicare-approved amount, capped at the Part A inpatient deductible.
Benefit periods
Hospice is covered in two 90-day benefit periods, followed by an unlimited number of 60-day periods. At the start of each one, the hospice doctor must recertify that the person is still terminally ill. After the first six months, recertification also requires a face-to-face visit with a hospice doctor or nurse practitioner.
Your rights under the benefit
- You can change hospice providers once in each benefit period.
- You can stop hospice at any time and return to regular Medicare coverage. See can you leave hospice?
- You can ask the hospice for a written list of items, services and drugs it has decided are not related to the terminal illness, so you know what it will not cover.
Medicare Advantage, Medi-Cal and private insurance
If your loved one has a Medicare Advantage plan, hospice is still paid through Original Medicare, and the plan may continue to cover extra benefits. Medi-Cal and most employer and private plans also cover hospice, often with similar rules. Check with the plan for details.
Sources
Costs and rules can change. Confirm current details with Medicare (1-800-633-4227) or your health plan. This guide is general information, not legal or financial advice.