Medicare covers hospice care for beneficiaries who meet specific eligibility criteria, including care provided in the patient’s private residence (home hospice). Hospice shifts the focus from seeking a cure for a terminal illness to providing comfort and managing symptoms, known as palliative care. The goal is to maximize the patient’s quality of life during their final stages, ensuring they are comfortable and pain-free. This care is delivered through a team-based approach that supports both the patient and their family.
Medicare Hospice Eligibility Requirements
To qualify for the Medicare hospice benefit, a patient must be enrolled in Medicare Part A. A medical certification is required from the hospice medical director and the patient’s attending physician, if one is chosen, stating the patient has a terminal illness. This certification must confirm a prognosis of six months or less to live if the illness runs its normal course, based on the physician’s clinical judgment.
The patient must sign an election statement, formally choosing the hospice benefit. By electing this benefit, the patient agrees to pursue comfort care for the terminal illness and waives Medicare payments for curative treatments related to that illness. The care must be provided by a Medicare-certified hospice agency. The initial benefit period consists of two 90-day periods, followed by unlimited 60-day periods, all requiring physician recertification.
Specific Services Included in Home Hospice Care
Medicare’s coverage for home hospice is comprehensive, ensuring all needs related to the terminal illness are met. This includes nursing care, ranging from intermittent scheduled visits to continuous home care during brief periods of crisis. Medical equipment (e.g., wheelchairs, hospital beds, oxygen) and necessary medical supplies (e.g., bandages, catheters) are also covered.
Drugs intended to manage pain and control symptoms related to the terminal illness are covered. The hospice benefit also includes:
- Services from hospice aides for personal care, such as bathing and dressing.
- Homemaker services for light household tasks.
- Physical, occupational, and speech-language therapy.
- Medical social services, dietary counseling, and spiritual counseling.
- Individual and family counseling for grief and loss, available both before and after the patient’s death.
All services are provided according to an individualized written plan of care established by the hospice interdisciplinary group. This plan is developed in collaboration with the patient, their representative, and the primary caregiver.
Patient Financial Responsibilities
The Medicare hospice benefit is generally covered with no deductible or copayment for the services provided by the hospice agency. This means that for the vast majority of covered hospice services, the patient pays nothing out-of-pocket. However, there are two minor exceptions where a small cost-sharing amount may apply to the patient.
One exception is a minimal copayment for prescription drugs used for pain and symptom management. This copayment is typically no more than 5% of the cost for each prescription. A second exception applies to short-term inpatient respite care, which is provided in a facility to give the primary caregiver a break. For each day of respite care, the patient may owe a small daily coinsurance amount, which is 5% of the Medicare payment for that day.
Important Limitations of the Hospice Benefit
Electing the Medicare hospice benefit involves accepting certain limitations, primarily the agreement to focus on comfort care. Medicare will not cover treatment intended to cure the terminal illness or any related conditions once the benefit is elected. This includes prescription drugs or equipment used with a curative intent, rather than for symptom management.
Medicare will continue to cover services for health issues entirely unrelated to the terminal prognosis under other parts of the program. However, the hospice benefit is highly specific, covering only services, drugs, and equipment related to the terminal illness. Another limitation concerns room and board; if the patient resides in a nursing home or assisted living facility, Medicare covers the hospice services provided there but not the facility’s living expenses.
A patient can choose to revoke the hospice benefit at any time if they wish to seek curative treatment again. By revoking the benefit, the patient reverts to standard Medicare coverage for all medical needs. They retain the right to re-elect the hospice benefit later if their condition requires it.