Medicare beneficiaries needing hospice care may be covered

Hospice care has the goal of providing comfort and relief from pain and other symptoms to terminally ill patients during the final days of their life. Hospice may also provide emotional and spiritual care to patients and their families. This type of care is called palliative care.

Hospice can take place in the home or in an inpatient hospice facility, depending on individual circumstances.

Medicare Part A, Medicaid and most private insurance plans cover hospice care if you or your loved one meets certain conditions.¹ Even if with a Medicare Advantage plan, Medicare Part A will still cover the costs associated with hospice care.

Hospice care can be covered by Medicare if all the below conditions are met for you or your loved one.

1. A hospice doctor and your doctor (if you have one) must certify that you are terminally ill (you have 6 months or less to live)*
2. You accept palliative care (care for comfort only) instead of care to try to cure your illness
3. You sign a statement that shows you choose hospice care over other Medicare-covered benefits for treating your terminal illness and any related conditions

*NOTE: You may be able to continue to get hospice care covered by Medicare if the hospice medical director or hospice doctor recertifies you are still terminally ill.

Hospice care provided through Medicare is usually given in your home or a long-term care facility you live in such as a nursing home. Generally, hospice coverage should cover most of your health care needs, but if not Medicare Parts A and B will still pay for covered benefits and services for health problems unrelated to your terminal illness and accompanying conditions.

Medicare.gov provides the following list of covered items for hospice:

• All items and services needed for pain relief and symptom management
• Medical, nursing, and social services
• Drugs for pain management
• Durable medical equipment for pain relief and symptom management
• Aide and homemaker services
• Other covered services you need to manage your pain and other symptoms, as well as spiritual and grief counseling for you and your family

Other health care services may also be covered under your hospice plan, but it depends on the specific terminal illness and related conditions you have. These additional covered services could include things such as physical therapy services, dietary counseling, and spiritual and grief counseling for you and your family. See a more complete list from Medicare.gov here.

If qualified for coverage by meeting the conditions listed above, you pay nothing for hospice care. However, there may be a $5 copayment for each prescription drug (or other similar item) for pain relief and symptom management, and in some cases, there may also be a charge of 5 percent of the Medicare-approved amount for inpatient respite care.

Medicare will not cover certain things once you start receiving hospice benefits. Medicare won’t cover the following while you’re getting hospice benefits:

• Any treatments intended to help cure your terminal illness and/or related conditions
• Prescription drugs that work to cure your illness
• Care from a hospice provider that was not set up by your hospice medical team (More simply, you cannot get care from more than one hospice provider, but you can still see your regular doctor or nurse practitioner if he or she is your chosen attending medical professional to supervise your hospice care)
• Room and board costs if you get hospice care in your home, if you live in a nursing home, or if you get hospice care at a hospice inpatient facility (NOTE: short-term inpatient or respite care services follow different rules)
• Any care you get as a hospital inpatient, hospital outpatient or during ambulance transportation that is not arranged by your hospice team or that is unrelated to your terminal illness and related conditions

Also, hospice benefits under Medicare Part A do not cover curative care. This means the hospice benefit will not pay for any treatment to try and cure the primary or related condition or illness. Keep in mind that a hospice patient can resume curative treatment at any time, but hospice will not pay for it. 

If you have Original Medicare (Parts A & B) and need hospice care, Medicare Part A will cover all costs if you meet the eligibility requirements listed above. Talk with you or your loved one’s doctor to learn what next steps are appropriate. If you have a Medicare Advantage plan, Medicare Part A still covers the costs associated with hospice care. Contact your plan’s customer service department to speak to a representative if you have questions.

And finally, another great resource is the Medicare Hospice Benefits official government booklet from the Centers for Medicare and Medicaid.