Does Medicare Cover Hospice Facility?

Hospice care offers a specialized approach to support individuals nearing the end of life, focusing on comfort and quality of life rather than curative treatments. This type of care addresses medical, physical, social, emotional, and spiritual needs for patients, along with providing support to their families. Medicare offers a specific benefit to help cover these services, recognizing the importance of comprehensive care during a sensitive time.

Medicare Hospice Eligibility Requirements

To qualify for the Medicare Hospice Benefit, an individual must meet specific conditions. A doctor must certify that the patient has a terminal illness with a life expectancy of six months or less.

An individual must also choose to receive comfort care, or palliative care, for their terminal illness instead of treatments aimed at curing it. This choice signifies a shift in focus toward managing symptoms and pain. Patients are required to sign a statement indicating their election of the hospice benefit with a specific Medicare-approved hospice provider.

The hospice benefit begins with two 90-day periods, followed by an unlimited number of 60-day benefit periods. After the initial 90-day periods, a hospice physician or nurse practitioner must conduct a face-to-face encounter to recertify that the patient remains terminally ill. Patients have the flexibility to change their hospice provider once during each benefit period or to revoke the benefit and return to standard Medicare coverage if their condition improves or their care needs change.

Services Covered Under the Medicare Hospice Benefit

The Medicare Hospice Benefit provides a comprehensive range of services. This includes doctor services, nursing care, and necessary medical equipment like wheelchairs, walkers, or hospital beds. Medical supplies, such as bandages and catheters, are also covered.

Prescription drugs for symptom control and pain relief are part of the covered services. Hospice aide and homemaker services assist with personal care and light household tasks. Physical, occupational, and speech-language therapy, along with social worker services and dietary counseling, address various aspects of a patient’s health and daily living.

Medicare covers short-term inpatient care for pain control or symptom management that cannot be effectively managed at home. This care can be provided in a hospice facility, hospital, or skilled nursing facility. The intent of this inpatient stay is to stabilize acute symptoms, allowing the patient to return to their home environment once symptoms are under control.

Respite care is another covered service, allowing primary caregivers a temporary break from their caregiving duties. Medicare covers up to five consecutive days of inpatient respite care, which can also take place in a hospice facility, hospital, or skilled nursing facility. This provision helps prevent caregiver burnout and supports the family unit. Continuous home care is available during periods of crisis, provided in the patient’s home, with a focus on intensive nursing care for at least eight hours in a 24-hour period to manage acute symptoms. Bereavement counseling is offered to the family after the patient’s death.

Understanding Costs and Limitations

The Medicare Hospice Benefit results in minimal out-of-pocket expenses for beneficiaries. There are no deductibles for hospice care received from a Medicare-approved provider.

A small copayment may apply for certain services. For instance, a copayment of up to $5 per prescription may be required for outpatient drugs used for symptom control and pain relief. For inpatient respite care, a copayment of up to 5% of the Medicare-approved amount may be charged per day, though total copayments for respite care are limited annually.

However, certain services and situations are not covered by the Medicare Hospice Benefit. Treatment intended to cure the terminal illness is not covered once the hospice benefit is elected. Care received from a provider not arranged by the hospice team is also not covered, underscoring the importance of coordinating all care through the chosen hospice agency.

A significant limitation is that Medicare does not cover room and board costs for long-term residential stays in a nursing home or hospice inpatient facility. While short-term inpatient care and respite care in a facility are covered for specific medical needs or caregiver relief, the cost of living in such a facility for general residency is the patient’s responsibility. Emergency room visits or ambulance transportation are not covered unless arranged by the hospice team or if they are unrelated to the terminal illness.