What Medicare's hospice benefit covers, and what it does not

Who qualifies

You need Medicare Part A and must meet all of these conditions:

• Your hospice doctor and your regular doctor, if you have one, certify that you are terminally ill. In Medicare's rules that means a life expectancy of 6 months or less if the illness runs its normal course.
• You accept comfort care (palliative care) instead of care to cure the illness.
• You sign a statement choosing hospice care instead of other Medicare-covered treatments for the terminal illness and related conditions.

Choosing hospice is not final. You keep the right to stop hospice care at any time and go back to treatment. See how to switch or stop hospice.

Sources: [1], [2]

What the benefit covers

Once hospice starts, Medicare covers what you need for the terminal illness and related conditions, from a Medicare-approved hospice. Care usually happens at home, which can also mean a nursing home or assisted living. Depending on the plan of care, it 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 you and your family
• Short-term inpatient care for pain and symptom management
• Short-term respite care, so a family caregiver can rest
• Any other Medicare-covered service the hospice team recommends to manage the illness

Before choosing hospice, you can get a one-time consultation with a hospice medical director or hospice doctor about your options, even if you then decide against hospice.

Sources: [2], [3]

What it does not cover

• Treatment meant to cure the terminal illness or related conditions.
• Prescription drugs that are not for the terminal illness or related conditions. Medicare drug coverage (Part D) may cover them.
• Care from a provider the hospice team did not set up. You can still see your regular doctor, nurse practitioner or physician assistant if you chose them as your attending professional.
• Room and board, at home or in a nursing home. When the hospice team arranges short-term inpatient or respite care, Medicare covers that stay.
• Emergency room care, hospital stays and ambulance rides, unless the hospice team arranges them or they are unrelated to the terminal illness.

Call the hospice team before you get any of these services, or you might pay the full cost.

Sources: [1], [2]

What you pay

• Nothing for hospice care from a Medicare-approved hospice. There is no deductible.
• Your usual Part A and Part B premiums.
• A copayment of up to $5 for each outpatient prescription for pain and symptom management.
• 5% of the Medicare-approved amount for inpatient respite care. It cannot be more than the inpatient deductible.

Health problems that are not part of the terminal illness are still covered the usual way, with the usual deductibles and coinsurance.

Sources: [1], [2]

How long hospice can last

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, the hospice medical director or another hospice doctor must recertify that you are terminally ill. After 6 months, that recertification follows a face-to-face meeting. You do not need to choose hospice again for each new period.

If someone lives longer than 6 months, hospice can continue as long as the doctor recertifies.

Sources: [1], [2], [4]

If you have a Medicare Advantage Plan

Once hospice starts, Original Medicare covers everything related to the terminal illness, even if you stay in a Medicare Advantage Plan. You can keep the plan as long as you pay its premiums. It still covers extra benefits, like dental and vision, and care for health problems unrelated to the terminal illness. Your plan must help you find a Medicare-approved hospice in your area.

Source: [2]