Medicare Part A covers hospice services for individuals residing in a nursing home through the Medicare Hospice Benefit. Hospice care is a distinct benefit focused on palliative treatment, prioritizing comfort and symptom management for a terminal illness. This coverage extends to the patient’s place of residence, including skilled nursing or long-term care facilities, and covers comprehensive care provided by a certified hospice agency. A significant distinction exists, however, regarding the costs of the nursing home stay itself.
Requirements for Medicare Hospice Coverage
To qualify for the Medicare Hospice Benefit, a beneficiary must be entitled to Medicare Part A and meet specific clinical and elective criteria. The primary medical requirement is certification from both the patient’s attending physician and the hospice medical director that the patient is terminally ill. This certification indicates that the patient has a prognosis of six months or less to live if the illness runs its expected course. This clinical judgment must be supported by documentation within the patient’s medical record.
The second requirement is a voluntary choice, where the patient or their authorized representative signs a statement electing the hospice benefit. By making this election, the individual agrees to waive their right to Medicare coverage for curative treatments related to the terminal illness, choosing instead to focus solely on palliative care. Hospice coverage is initially provided for two 90-day benefit periods, followed by an unlimited number of subsequent 60-day periods, provided the patient is continually recertified as terminally ill.
Distinguishing Hospice Care from Nursing Home Room and Board
The most frequent source of confusion is the financial responsibility for the nursing home stay when a patient elects hospice. While Medicare covers the specialized hospice services delivered in a nursing home, it strictly excludes payment for room and board. This means the patient or another payer remains responsible for the custodial costs associated with residing in the facility. Medicare only pays the hospice agency for the palliative care it provides, not for the patient’s lodging.
In this context, “room and board” includes the costs of the nursing home facility’s general maintenance, meals, housekeeping, and the general personal care provided by the facility’s staff. The responsibility for these costs does not shift to Medicare simply because the patient has elected hospice care. The hospice agency and the nursing home must have a formal, written agreement detailing how they will coordinate care for the patient.
An important exception occurs when the patient’s symptoms become acute and cannot be managed by the routine level of hospice care. If the hospice Interdisciplinary Group determines the patient requires General Inpatient Care (GIP) or short-term Inpatient Respite Care, Medicare will cover the institutional stay for that brief period. GIP is provided for crisis management of pain or symptoms, and Respite Care is a short-term stay, limited to five consecutive days, to provide relief for the primary caregiver. For the majority of the patient’s time, they are receiving Routine Home Care, and the room and board exclusion applies.
What Services Are Covered Under the Hospice Benefit
The Medicare Hospice Benefit covers virtually all services and supplies necessary for the palliation and management of the terminal illness. These services are provided by the chosen Medicare-certified hospice agency and are covered at 100% with very few exceptions for patient cost-sharing. A comprehensive list of covered services must be included in the patient’s individualized plan of care.
The benefit covers services coordinated and managed by the hospice’s Interdisciplinary Group, ensuring seamless, holistic care within the nursing home setting. Covered services include:
- Physician services, skilled nursing care, and medical social services.
- Medications for pain and symptom control related to the terminal illness.
- Durable medical equipment, such as wheelchairs, hospital beds, and necessary supplies.
- Physical therapy, occupational therapy, and speech-language pathology services for symptom management or maintaining basic functional abilities.
- Home health aide and homemaker services to assist with personal care.
- Counseling services, including dietary, spiritual, and bereavement counseling for the patient and family members.
Navigating Enrollment and Care Coordination
The initial step in receiving the benefit is selecting a Medicare-approved hospice agency that services the nursing home where the patient resides. Once the patient meets the clinical criteria and signs the election statement, the hospice agency assumes primary responsibility for the patient’s care related to the terminal illness. The hospice care team, known as the Interdisciplinary Group (IDG), coordinates all services with the nursing home staff.
The IDG typically includes a physician, a registered nurse, a social worker, and a spiritual counselor. This team oversees the creation and execution of the plan of care, ensuring the hospice services are consistent with the patient’s needs. The written agreement between the hospice and the nursing home is a regulatory requirement that formalizes the responsibilities of each entity. Patients retain the right to revoke the hospice benefit at any time, which immediately returns them to standard Medicare coverage and the option to pursue curative treatment.