Understanding Medicare and Hospice Coverage
Learn about the Ins and Outs of Medicare Hospice Benefits and Costs
Medicare Hospice coverage is as follows:
You qualify for hospice care if you have Medicare Part A (Hospital Insurance) and meet all of these conditions:
- Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (with a life expectancy of 6 months or less).
- You accept comfort care (palliative care) instead of care to cure your illness.
You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions. - If you qualify, you can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods. You have the right to change your hospice provider once during each benefit period.
You can usually get Medicare-approved hospice care in your home or other facility where you live, like a nursing home. You can also get hospice care in an inpatient hospice facility. If your hospice care team determines you need inpatient care at a hospital, they must make the arrangements for your stay. If they don’t, you might be responsible for the entire cost of your hospital care.
Costs for Hospice with Medicare:
- You pay nothing for hospice care as long as you get your care from a Medicare-approved hospice provider.
- You pay a copayment of up to $5 for each prescription for outpatient drugs for pain and symptom management. In the rare case the hospice benefit doesn’t cover your drug, your hospice provider should contact your plan to see if Part D covers it. The hospice provider will inform you if any drugs or services aren’t covered, and if you’ll be required to pay for them.
- You may pay 5% of the Medicare-approved amount for inpatient respite care. Your copay can’t exceed the inpatient hospital deductible for the year.
- Original Medicare will still pay for covered benefits for any health problems that aren’t part of your terminal illness and related conditions, but you’ll owe and deductible and coinsurance amounts that apply.
- You may have to pay for room and board if you live in a facility (like a nursing home) and choose to get hospice care.
Once you choose hospice care, your hospice benefit should cover everything you need. You and your family will work with your hospice care team to set up your plan of care.
Medicare DOES NOT COVER any of these once your hospice benefit starts:
- Treatment intended to cure your terminal illness and/or related conditions. Talk with your doctor if you’re thinking about getting treatment to cure your illness.
- Prescription drugs to cure your illness (rather than for symptom control or pain relief).
- Care from any hospice provider that wasn’t set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.
- Room and board. Medicare doesn’t cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility.
- Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness and related conditions.
