Does Medicare cover hospice?

You are handed a folder at the worst possible moment and asked to sign something. Hospice is a Medicare benefit you have to choose in writing, and the choice is reversible. Medicare says so itself, in a sentence that sits behind a drawer on its own coverage page.

Does Medicare cover hospice?

Medicare Part A covers hospice care if you are eligible. Medicare describes it in one line: end-of-life care for people with illnesses that cannot be cured. You pay nothing for the covered services, although other costs can still apply, and the benefit runs in periods rather than continuously.

Where it happens is wider than the word suggests. Medicare says you can usually get Medicare-approved hospice care in your home, or in another facility where you live, such as an assisted living facility or a nursing home.

An inpatient hospice facility is also possible if you meet certain conditions, and Medicare states that as a condition rather than an entitlement.

One arrangement carries a warning attached to it. If your hospice care team decides you need inpatient care at a hospital, they must make the arrangements for your stay. If they do not, Medicare says you might be responsible for the entire cost of that hospital care.

So the benefit follows the person rather than the building, and the team stays in the middle of every arrangement inside it.

Who qualifies for hospice care?

You must have Part A and meet three conditions. Your hospice doctor and your regular doctor, if you have one, certify that you are terminally ill with a life expectancy of 6 months or less. You accept comfort care instead of care to cure. You sign a statement choosing hospice over other Medicare-covered treatments.

Medicare's own word for comfort care is palliative care, and it uses both. The condition is about the aim of the treatment rather than about stopping treatment: you are accepting care aimed at comfort for your terminal illness and related conditions.

Only two people can make the certification, and Medicare names them. Your hospice doctor and your regular doctor, if you have one, are the only ones who can certify that you are terminally ill with a life expectancy of 6 months or less.

Only two people can make the certification, and Medicare names them.

The six months is not a deadline on the benefit. After 6 months you can continue getting hospice care as long as the hospice medical director or hospice doctor recertifies that you are still terminally ill, after a face to face meeting with the hospice doctor or a hospice nurse practitioner.

The signing has its own timing rule. The election statement identifies the hospice providing your care and tells you the start date of services and who you have chosen as your attending doctor, and Medicare says it must be completed before you get any hospice services.

What does the hospice benefit include?

Medicare says that once you choose hospice, your benefit should cover everything you need, and you and your family work with the hospice team to set up a plan of care. That plan is where the benefit becomes specific, and Medicare publishes what it might include rather than what it always will.

The list is long and it is worth reading whole. Nursing and medical services, doctors' services, drugs for pain and symptom management, durable medical equipment for pain relief and symptom management, and medical supplies such as bandages or catheters.

It continues past the clinical. Aide and homemaker services, dietary counseling, social services, and spiritual and grief counseling for you and your family.

Three kinds of therapy sit on it too, physical, occupational and speech-language pathology, along with short term inpatient care for pain and symptom management.

Respite care has its own shape. Inpatient respite care runs for up to 5 days at a time, your hospice provider arranges it, and Medicare says you can get it more than once but only on an occasional basis.

The hedge in Medicare's own sentence matters as much as the list. It says your plan of care might include any or all of these services, depending on your terminal illness and related conditions. The list describes what the benefit can reach, not what every plan contains.

Behind the list is a team, and one fact about it is worth having in advance. A hospice nurse and doctor are on call 24 hours a day, 7 days a week. The team may also include your family, your regular doctor, nurses, counselors, social workers, pharmacists, therapists, aides, homemakers, volunteers and chaplains.

You are not locked to the first provider you pick. Medicare states that you have the right to change your hospice provider once during each benefit period.

What do I pay for hospice?

You pay nothing for hospice care if you get your care from a Medicare-approved hospice provider. Three costs can still appear beside that: a small copayment for outpatient drugs for pain and symptom management, a share of the approved amount for inpatient respite care, and room and board where you live.

Take those one at a time, because they behave differently. The drug copayment applies to each prescription for outpatient pain and symptom management, and Medicare caps it. The respite share is a percentage of the Medicare-approved amount, and Medicare states that this copayment cannot be more than the inpatient deductible amount.

Room and board works differently again, and it is not a copayment at all. Medicare does not 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.

The exact amounts for the first two are plan year figures, and on this publication they belong to the Part A cost page rather than to this one. What belongs here is which three doors a cost can come through.

Two things run alongside the benefit and are billed on their own footing. Original Medicare still pays for covered benefits for health problems that are not part of your terminal illness and related conditions, and you will owe any deductible and coinsurance amounts that apply.

The provider carries a duty in all of this. It must tell you if any drugs or services are not covered and why, and whether you will be required to pay for them. You can also ask for an addendum to your election statement listing the items, services and drugs your hospice will not cover because they are unrelated to your terminal illness.

Checking that a provider is Medicare-approved is a question rather than a search. Medicare says you can ask your doctor, the hospice provider, your state hospice organization or your state health department.

How long does coverage last?

Hospice coverage is measured in benefit periods rather than in a single stretch. If you qualify, you get two 90 day benefit periods, followed by an unlimited number of 60 day benefit periods. The periods get shorter once, and then they stop counting down.

The ladder is short enough to hold in your head.

The benefit period	How long it runs	The trap
First period	90 days	Reading it as the whole benefit
Second period	90 days	Expecting the length to change here
Every period after	60 days, no limit on how many	Hearing shorter and reading running out

What keeps the ladder going is the recertification. After 6 months, hospice care continues as long as the hospice medical director or hospice doctor recertifies that you are still terminally ill, following a face to face meeting.

So the 6 months in the eligibility test is a prognosis at a point in time rather than a countdown on the benefit. Medicare states no ceiling on the number of 60 day periods, and this page states none either.

Each new benefit period also renews one right, the right to change your hospice provider. Medicare attaches it to each benefit period rather than to the stay as a whole.

Can I leave hospice and return to regular Medicare?

Yes. Medicare's own answer is that you always have the right to stop hospice care at any time, and it names two circumstances: your health improves, or your illness goes into remission. You or your doctor may decide hospice is no longer needed.

Stopping takes a form. If you choose to stop, you sign a form that includes the end date for your care.

There is a second way it can end, and it is not the same thing. If your doctor determines your life expectancy is no longer 6 months or less, the hospice may discharge you, until your doctor certifies again that you are terminally ill with a life expectancy of 6 months or less.

Call the pair of them The Two Signatures. Medicare states hospice entry as a document that must be completed before any hospice service, and hospice exit as a right you always hold that also takes a signed form.

Then it writes a rule about the calendar rather than about either form. No one from your hospice care team should ask you to sign forms about stopping hospice when you start hospice, and you should not sign or date any such form until the actual date you want your care to stop.

Both sentences are the government's. Noticing that Medicare wrote a safeguard about when a signature is collected, rather than about what the form says, is ours. No claim is made here about how often it happens.

What comes back is the coverage you had. Medicare states that if you stop hospice care, your Original Medicare coverage will start again, or your coverage in a Medicare Advantage Plan or other Medicare health plan if you have one.

For a plan specifically, Medicare adds a date: it starts again on the first day of the following month. If you qualify, you can go back to hospice care at any time.

What this means for you

Medicare Part A covers hospice, and the covered care itself costs you nothing from a Medicare-approved provider. Getting in takes a certification of a life expectancy of 6 months or less from two doctors, and a statement you sign choosing comfort care.

The clock is not what people fear. Two 90 day periods run first, then 60 day periods with no limit on how many, held open by recertification rather than by a countdown.

And the door opens both ways. You can stop at any time, your earlier coverage starts again, and you can return if you still qualify. The Coverage section carries skilled nursing facility care and home health care for the two routes beside this one.

FAQ

What stops being covered once hospice starts?

Medicare names five things. Treatment intended to cure your terminal illness or related conditions. Prescription drugs to cure your illness, as distinct from drugs for symptom control or pain relief. Care from any hospice provider that was not set up by the hospice medical team.

Room and board. And care you get as a hospital outpatient or inpatient, or ambulance transportation, unless your hospice team arranged it or it is unrelated to your terminal illness and related conditions.

One exception runs through the third item: you can still see your regular doctor or nurse practitioner if you have chosen them as the attending medical professional helping supervise your care. Medicare's instruction is to contact your hospice team before you get any of these services, or you might have to pay the entire cost.

Will I have to pay for a nursing home if I go on hospice there?

Possibly, and the answer turns on room and board rather than on the hospice care itself. Medicare states it does not 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.

It says separately that you may have to pay for room and board if you live in a facility such as a nursing home and choose to get hospice care.

There is one carve out inside that rule. If the hospice team determines you need short term inpatient care or respite care services that they arrange, Medicare will cover your stay in that facility. The difference is who arranged it and why, rather than what the building is called.

What happens to my Medicare Advantage plan if I start hospice?

It stays where it is, and Medicare describes the split plainly. Your plan must help you locate a Medicare-approved hospice provider in your area.

Original Medicare will cover everything you need related to your terminal illness once your hospice benefit starts, even if you stay in your plan, and you can stay in the plan as long as you keep paying your premiums.

Your plan can still cover services that are not part of your terminal illness and related conditions, and you can get those from providers in the plan's network or from providers that take Original Medicare.

What you pay depends on the plan and on whether you follow its coverage rules. Extra benefits the plan offers continue while you keep paying for them.

Can I find out what my hospice will not pay for?

Yes, and Medicare gives you two routes with a deadline on one of them. You can ask your hospice provider for a list of items, services and drugs they have determined are not related to your terminal illness and related conditions, and that list must include why they made that determination.

Your provider must give you the list within 3 to 5 days of your request, depending on when you asked, and must also give it to your non-hospice providers or to Medicare if requested.

Separately, you can ask for an addendum to your election statement listing the same kind of items. If your coverage changes, your provider gives you an updated addendum.

Does hospice coverage run out after six months?

No, and the six months is doing a different job than families expect. It is the prognosis that has to be certified for you to qualify: your hospice doctor and your regular doctor, if you have one, certify that you are terminally ill with a life expectancy of 6 months or less.

After 6 months you can continue getting hospice care as long as the hospice medical director or hospice doctor recertifies that you are still terminally ill, following a face to face meeting with the hospice doctor or a hospice nurse practitioner.

The benefit itself runs as two 90 day periods followed by an unlimited number of 60 day periods, so what keeps it going is the recertification rather than a countdown.