Levels of Hospice Care as Defined by Medicare

Hospice nurse helping male patient in bed

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When a doctor determines that a patient most likely has no more than six months to live, the person or their family may choose to stop trying to cure the illness, and opt to receive hospice care instead.

Hospice, also called "comfort care," focuses on managing pain and keeping a patient comfortable so that he or she can enjoy a good quality of life for the remainder of the time left.

Medicare defines four distinct levels of hospice care. This benefit provides goods and services to allow you and your family to stay together in the comfort of your home, unless you need care in an inpatient facility, for the duration of your terminal illness.

The patient is still responsible for the deductible and coinsurance amounts for expenses incurred due to health problems not related to the terminal illness.

One patient may experience all four levels, perhaps in just a week or 10 days of hospice services. Another patient may experience one level of care throughout the duration of his or her hospice care. Each level of care meets specific needs, and every hospice patient is unique.

Every Medicare-certified hospice provider must provide these four levels of care:

Level 1: Routine Home Care

Routine home care is the basic level of care under the hospice benefit. It is covered for homebound individuals with Medicare part A and B who are under the care of a doctor who has specified the services are needed. The amount, frequency, and time period of the treatment must be reasonable and you must be expected to improve in a reasonable and predictable amount of time.

  • Part-time or intermittent skilled nursing services
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology services
  • Medical social services
  • Part-time or intermittent home health aide services
  • Medical supplies for use at home
  • Durable medical equipment (Medicare will cover 80% of the cost)
  • Injectable osteoporosis drugs

Level 2: Continuous Home Care

Continuous home care is available during times of crisis when a higher level of continuous care is needed for at least eight hours in a 24-hour period to achieve palliation or management of acute medical symptoms. Fifty percent of the care needed must be provided by a nurse.

Symptoms Requiring 24/7 Care

Some examples of symptoms requiring continuous care would be:

  • Unrelieved pain
  • Severe nausea and vomiting
  • Severe shortness of breath
  • Anxiety or panic attacks
  • A breakdown in the primary caregiver support system

Level 3: General Inpatient Care

Some patients have short-term symptoms so severe they cannot get adequate treatment at home, or they may feel more comfortable getting treatment at an inpatient facility.

Symptoms requiring inpatient care are the same as those requiring continuous care, only the setting of care may be different. With inpatient care, nurses are available around the clock to administer medications, treatments, and emotional support to make the patient more comfortable.

Inpatient Facilities

There are several types of facilities that offer inpatient hospice services:

  • A free-standing facility owned and operated by a hospice company
  • An inpatient hospice unit within a hospital
  • A hospice unit in a skilled nursing facility (nursing home)

Level 4: Respite Care

Respite care services are more for the family than for the patient. If the patient does not meet the criteria to qualify them for continuous care or inpatient care, but the family is having a difficult time, respite care may be an option.

If a patient’s family is the primary source of care and cannot meet their loved one's needs due to caregiver stress or other extenuating circumstances, a patient may temporarily be admitted to an inpatient environment to give the family a needed break or respite.

There is a five-day limit on respite care. Once that period expires, the patient is discharged and returns home.

Determining Level of Care

In order to qualify for hospice care, the patient's doctor, and often a hospice doctor as well, must determine that the patient is terminally ill, with a life expectancy of six months or less; the decision to treat someone at a higher level of care falls to the hospice physician.

With four levels in place, no terminally ill patient should ever be left without the appropriate care.

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Article Sources

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  1. Harris PS, Stalam T, Ache KA, et al. Can hospices predict which patients will die within six months?. J Palliat Med. 2014;17(8):894-8. doi:10.1089/jpm.2013.0631

  2. Samaritan Healthcare & Hospice. What are the four levels of hospice care?

  3. Medicare.gov. Home health services coverage.

  4. CGS. Continuous home care.

  5. Medicare Benefit Policy Manual. Centers for Medicare and Medicaid Services.

  6. How hospice works. Medicare.