Medicare Part A offers a comprehensive hospice benefit focused on comfort and quality of life rather than curative treatment. This care provides support for the patient and their family near the end of life. While the benefit requires a terminal prognosis, coverage duration is not a fixed cap but a structure of renewable periods. Medicare pays for hospice care as long as the patient continues to meet the necessary eligibility requirements through this established structure.
Initial Eligibility for Coverage
To establish eligibility for Medicare hospice coverage, two primary conditions must be met. First, the patient must be entitled to Medicare Part A. The second condition requires a certification of terminal illness from both the patient’s treating physician (if one exists) and the hospice medical director.
This certification formally states that the patient has a prognosis of six months or less to live if the illness runs its normal course. By electing the hospice benefit, the patient signs a statement choosing comfort-focused care for their terminal illness and related conditions instead of treatment intended to cure the illness. This election is the gateway to accessing the structured benefit periods that determine the length of Medicare coverage.
Understanding the Medicare Hospice Benefit Periods
Medicare’s coverage is structured into distinct benefit periods that can continue indefinitely as long as the patient remains eligible. The benefit begins with two initial periods, each lasting 90 days. Following the completion of the two 90-day periods, coverage shifts to an unlimited number of subsequent 60-day benefit periods. Coverage continues through these extensions as long as the patient meets the criteria for being terminally ill.
To transition from one benefit period to the next, a physician must recertify that the patient is still terminally ill with a life expectancy of six months or less. After the second 90-day period, and for every subsequent 60-day period, a hospice physician or hospice nurse practitioner must conduct a face-to-face encounter with the patient. This encounter must document the clinical findings that support the terminal prognosis and the continued need for hospice care. The coverage is renewable through this recertification process for as long as the eligibility criteria are met.
Covered Services and Patient Costs
The Medicare Hospice Benefit is comprehensive, ensuring that nearly all services related to the terminal illness are covered with minimal out-of-pocket costs to the patient.
Covered services include:
- Physician and nursing care, provided on an intermittent basis at the patient’s residence.
- Medications necessary for pain control and symptom management.
- Necessary medical equipment (e.g., wheelchairs, hospital beds, oxygen).
- Hospice aide and homemaker services.
- Physical and occupational therapy, and spiritual or grief counseling for the patient and family.
- Short-term inpatient care if symptoms cannot be managed at home.
- Short-term respite care, allowing the primary caregiver a break for up to five consecutive days.
Patient financial responsibility under the hospice benefit is generally low. There is no deductible for hospice care. The patient may be responsible for a minimal copayment of up to $5 for each prescription drug used for pain and symptom management. For inpatient respite care, the patient pays a coinsurance amount that is 5% of the Medicare-approved amount for the facility stay.
A significant exclusion from the Medicare benefit is payment for room and board. If a patient resides in a nursing facility or assisted living facility, Medicare does not cover the cost of the facility’s room and board, only the hospice services themselves. This cost is only covered by Medicare when the patient is receiving the short-term inpatient or respite levels of care.
Revocation and Transferring Hospice Providers
The patient maintains control over the hospice benefit and has the right to stop or change their care at any time. A patient can choose to stop receiving the Medicare hospice benefit, a process known as revocation. To revoke the benefit, the patient or their representative must provide the hospice provider with a signed written statement.
By revoking the benefit, the patient returns to standard Medicare coverage and can pursue curative treatments. The patient can re-elect the hospice benefit at a later time if they meet the eligibility criteria again. The benefit period timeline restarts upon re-election.
Separately, a patient has the option to transfer from one Medicare-certified hospice provider to another. This transfer is not considered a revocation of the benefit, and the patient may change providers once during each 90-day or 60-day benefit period. The transfer allows continuity of the benefit without resetting the current benefit period.