Overview of Medicare Hospice Benefits

Medicare's hospice benefit is a special part of Medicare that pays for hospice care. If you or a loved one have Medicare and are considering enrolling in hospice care, this article will explain what you need to know about how Medicare covers hospice care.

To be eligible for hospice coverage, you must have a life expectancy of fewer than six months. But if you live longer than six months, you can continue to receive hospice benefits as long as your hospice doctor recertifies that you're terminally ill. The recertification is initially after 90 days and 180 days, and then every 60 days thereafter.

Additionally, you must agree to forgo further curative treatment options for your terminal illness, instead choosing treatment options aimed at keeping you comfortable and maintaining as good a quality of life as possible. But if you decide that you do want to receive treatment for the terminal illness, you can choose to end your hospice coverage and return to regular Medicare coverage at any time.

If you have Medicare and choose a Medicare-certified hospice organization to provide your hospice care, nearly all of your costs will be covered.

man in hospital bed holding wife's hand
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What the Medicare Hospice Benefit Covers

The Medicare hospice benefit covers all of the care related to your terminal illness and necessary to keep you comfortable, as long as you receive your care from a Medicare-approved hospice vendor. It pays for:

  • Hospice physicians and nurses.
  • Medications necessary to keep you comfortable and control or prevent your symptoms.
  • Hospice home health aides to help with bathing and bed changes.
  • Medical equipment like a wheelchair or hospital bed necessary to keep you comfortable.
  • Social workers to help you get your affairs in order and to help you and your family deal with emotional difficulties and grief.
  • Respite care needed to give your caregiver a break.
  • Speech, occupational, or physical therapy needed to keep you comfortable or teach you how to cope with the changes your body is undergoing.
  • Dietician services if necessary.
  • Grief counseling for both you and your loved ones.
  • Inpatient admission if necessary for crisis management, approved by the hospice team, and received at a hospital or hospice facility contracted with your hospice organization.
  • Anything else the hospice team feels is necessary and related to keeping you comfortable and limiting the symptoms of your terminal illness.

What It Doesn't Cover

The Medicare hospice benefit doesn’t cover anything aimed at curing your terminal illness. For example, it might cover the cost of radiation therapy aimed at shrinking a tumor that is pressing against your spinal cord causing pain. But, it wouldn’t cover radiation therapy aimed at curing your disease. The key is whether the treatment is to control your symptoms so you can be comfortable (covered), or whether the treatment is an attempt to cure your terminal illness (not covered).

The Medicare hospice benefit also doesn’t cover the cost of room and board with the exception of short-term inpatient stays arranged by the hospice team or respite care of up to five days at a time. This isn’t usually a problem if you’re in your own home, which is where hospice care is generally provided.

But if you are in a nursing home, assisted living facility, board and care home, or living at a hospice facility, you’ll be responsible for covering your room and board costs. If it’s clear that you need to live in a nursing home, assisted living, or hospice house but can’t afford room and board, some hospice organizations will use charitable donations to assist you with those costs. This is usually done on a case-by-case basis, so if you predict this may be an issue, ask about it as you’re choosing which hospice organization to use. Depending on your financial situation, you may also find that Medicaid might cover the room and board costs associated with a nursing home.

Emergency room and ambulance services aren’t covered by Medicare hospice benefit unless your hospice team feels they’re necessary and arranges for you to receive those services, or unless they're unrelated to your terminal illness (for example, you're in hospice due to a terminal cancer diagnosis, but then you fall and break your leg and need to be transported to the emergency room for treatment that has nothing to do with your cancer).

What You'll Have to Pay

You will have a small copay of $5 for medications, although some hospice organizations waive this copay. You may have a 5% coinsurance for the cost of any respite care (meaning you pay 5% of the Medicare-approved cost). If you have a Medigap plan, it will cover some or all of your out-of-pocket costs for hospice.

You will pay the Medicare Part B deductible and coinsurance for any physician services you receive from a doctor that isn’t working for your hospice organization. And if you receive inpatient hospital care that's unrelated to your terminal condition, you'll be responsible for the normal Part A deductible (if you have a Medicare Advantage plan and choose to keep it, you'll pay your plan's normal cost-sharing if and when you need inpatient or outpatient care that's unrelated to your terminal condition and thus not covered by your hospice benefit).

You'll need to continue paying any Medicare premiums you were paying before you signed up for hospice. This includes the Medicare Part B premium, as well as a premium for Part D and/or a Medigap policy or Medicare Advantage plan, if you have any of those plans.

How the Medicare Hospice Benefit Works

The Medicare hospice benefit is part of Medicare Part A. When you sign up for hospice, whether you’re on Original Medicare or a Medicare Advantage Plan like a Medicare HMO, you’ll automatically (in most cases) be covered under the Original Medicare hospice benefit (there are some exceptions, under a pilot program described below).

If you're enrolled in a Medicare Advantage plan and you need hospice care, you can choose to remain in that plan as long as you continue to pay the premium, and the Medicare Advantage plan will continue to cover your healthcare needs that are not related to your hospice needs or your terminal condition (or you can choose to get care that's unrelated to your terminal illness via Original Medicare, with the regular deductibles and coinsurance that apply to that coverage).

But the Centers for Medicare and Medicaid Services rolled out a pilot program, starting in 2021, that allows Medicare Advantage plans to incorporate a hospice benefit. For insurers that participate, the program allows Medicare Advantage beneficiaries to receive hospice care via their existing insurance plan, with the same coordination of care that they receive for other services.

The Medicare Advantage hospice benefit pilot program is part of the Value-Based Insurance Design (VBID) model, which provides benefits to about 3.7 million Medicare beneficiaries as of 2022. In total, there are more than 63 million Medicare beneficiaries in the U.S.; about 42% have Medicare Advantage plans. So most Medicare Advantage enrollees are enrolled in plans that follow the normal procedure of having beneficiaries receive hospice benefits through Original Medicare, rather than being part of the VBID pilot program.

So in most cases, if you're enrolled in Medicare and you need hospice care, it will be provided by Original Medicare Part A. Medicare will pay the hospice organization a set dollar amount for every day you’re their patient. This set dollar-per-day rate is known as a per-diem rate.

The hospice organization pays for all of your necessary hospice care out of its per-diem rate. It gets this money every day whether or not the hospice nurse or home health aide came to visit you that day.

The hospice organization now acts a bit like an HMO in that you’re only allowed to get healthcare services related to your terminal illness from that hospice organization, or from another healthcare provider it contracts with. For example, if you need home oxygen and a hospital bed, you can’t get them from any medical equipment provider you choose. Instead, you must get them from the medical equipment provider your hospice organization contracts with, and your hospice must agree that you need these items.

You may still get healthcare services that aren’t related to your terminal illness from non-hospice providers. For example, if your terminal illness is cancer, you may continue to see your cardiologist for treatment of your heart arrhythmia since it has nothing to do with your terminal illness. Hospice won’t pay for the cardiologist out of its per-diem since that doctor’s visit wasn’t related to your terminal illness. However, Original Medicare Part B will pay for the cardiologist visit as it has in the past (or, if you have a Medicare Advantage plan that you've kept in place, it will cover the cardiologist visit under the plan's normal terms).

In another example, if your terminal illness is pulmonary hypertension and you need to be hospitalized because you tripped and broke your hip, Original Medicare Part A would pay for your hip-related hospitalization, and Original Medicare Part B would pay the doctor bills associated with your hip—or your Medicare Advantage plan would cover the treatment for your hip if you have an Advantage plan and choose to keep it after electing Medicare's hospice benefit.

So Medicare will cover the costs of palliative care for your terminal illness (with the Medicare hospice benefit) as well as healthcare costs unrelated to your terminal illness (with Medicare Parts A and B, or your Medicare Advantage plan), subject to the normal cost-sharing requirements for the services you need.

What Happens If You Change Your Mind

If you change your mind about hospice after you’ve signed up, you may revoke the Medicare hospice coverage and continue to receive care under Original Medicare, or a Medicare Advantage plan if you're enrolled in one.

If you want to continue to receive hospice services, but change your mind about the hospice organization you’ve chosen, you may switch to a different hospice organization. However, you can’t switch hospice organizations any time you wish. You may switch one time during the first 90 days of your care, one time during the second 90 days of your care, and once every 60 days thereafter. Hopefully, you’ll be able to find a hospice organization you’ll be happy with and not need to change.

Summary

Medicare has a robust hospice benefit. It is available to any beneficiary who is diagnosed with a terminal illness, as long as a doctor certifies that they're expected to live less than six months. In most cases, the hospice benefit is provided via Original Medicare (Part A), even for beneficiaries who are enrolled in Medicare Advantage plans. But a pilot program began in 2021 that allows some Medicare Advantage plans to provide hospice benefits directly to their enrollees.

A Word From Verywell

If you or a loved one with Medicare is in need of hospice care, rest assured that the program provides strong hospice benefits. Your costs will be minimal, and all necessary palliative care will be covered. If treatment is needed for a condition unrelated to the terminal illness, Medicare will continue to provide those benefits just like normal, in addition to the hospice care. The Medicare hospice benefit also includes inpatient respite care, so that your normal caregiver can have a chance to rest.

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6 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. Centers for Medicare and Medicaid Services. Medicare Learning Network. Hospice Payment System. January 2019.

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  4. Centers for Medicare and Medicaid Services. Newsroom. Medicare Advantage Value-Based Insurance Design Model Calendar Year 2021 Fact Sheet. December 19, 2019.

  5. Centers for Medicare and Medicaid Services. VBID Model Hospice Benefit Component Overview.

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