Does Medicare cover hospice care?

Q: Does Medicare cover hospice care?

A: Medicare covers almost all aspects of hospice care with little expense to patients or families, as long as a Medicare-approved hospice program is used. (Medicare has an online tool that beneficiaries can use to find and compare hospice programs). More than 1.5 million Medicare beneficiaries received hospice care in 2018, with services provided by more than 4,600 hospice programs nationwide.

Hospice programs­­ provide care and support for people who are terminally ill. Their focus is on comfort, or “palliative” care, not on curing an illness. When a Medicare beneficiary enters hospice, the hospice benefits are typically provided via Original Medicare, even if the beneficiary had previously been enrolled in Medicare Advantage.

(But starting in 2021, CMS began piloting a program that allows Medicare Advantage plans to include hospice benefits. In the first year, 53 Medicare Advantage plans, accounting for 8% of the market, participated in the pilot program. This grew to 115 plans in 2022.)

If a Medicare Advantage enrollee who is in hospice care (provided under Original Medicare) needs treatment for something that isn’t part of the terminal illness or related conditions, they can choose to use Original Medicare or their Medicare Advantage coverage.

To qualify for hospice benefits, a patient must be eligible for Medicare Part A, and a doctor must certify that the patient is terminally ill and has six months or less to live. Medicare-approved programs usually provide care in your home or other facility where you live, such as a nursing home or, in some cases, hospitals.

Medicare hospice coverage includes a full complement of medical and support services for a life-limiting illness, including drugs for pain relief and symptom management; medical, nursing, and social services; certain durable medical equipment, and other related services, including spiritual and grief counseling, which Medicare typically doesn’t cover.

There’s no deductible for hospice care, and copays for covered medications for pain or symptom management won’t exceed $5 (note that if a hospice patient needs medications that aren’t related to the terminal condition, their Part D plan would still have to cover them with its normal cost-sharing requirements, and their medical provider has to notify the Part D plan that the medications are unrelated to the terminal condition. This can be complicated, but it’s important for beneficiaries and their families to understand).

Medicare will also cover respite care, which is a short-term stay at a qualified hospice facility. It gives the usual caregiver a chance to rest. Respite care may last up to five days at a time.

Typically, Medicare does not cover room and board in facilities like nursing homes. (Here’s a list of services Medicare won’t cover.) But in-patient hospice care is covered during respite care, or at other times if the hospice program deems it necessary and arranges it. If a hospice patient receives respite care, the patient will be billed 5% of the Medicare-approved cost of the inpatient care, and Medicare will pay the other 95%. Medigap plans can help to cover the out-of-pocket costs associated with hospice care, including respite care.

Hospice care continues as long as the hospice medical director or doctor recertifies that you’re terminally ill.

Tags: eligibility, hospice care, Medicare Part A, Original Medicare, palliative care, respite care