Does Medicare Cover the Cost of Hospice Care?

Among its many benefits, Medicare provides coverage for hospice care, a specialized approach focused on comfort and support for individuals facing a terminal illness. Hospice care shifts the focus from curative treatments to managing symptoms and enhancing the quality of life during the final stages of a serious illness. This comprehensive benefit ensures that patients receive compassionate care in their preferred setting.

Qualifying for Coverage

A primary requirement involves certification by both the patient’s attending physician, if they have one, and a medical director from a Medicare-certified hospice program. These physicians must attest that the patient is terminally ill and has a life expectancy of six months or less, assuming the illness follows its natural course. This joint certification underscores the medical necessity of hospice services.

The patient must also make a conscious decision to elect hospice care, which involves choosing comfort-focused treatment over therapies intended to cure the terminal illness. This election is formalized by signing an election statement, acknowledging the palliative nature of hospice and waiving Medicare payments for curative treatments related to the terminal condition. While this choice emphasizes comfort, patients retain the right to revoke their hospice election at any time to pursue curative treatments, and they can re-elect hospice care later if they continue to meet the eligibility requirements. Hospice care is initially covered for two 90-day benefit periods, followed by an unlimited number of 60-day periods, provided ongoing recertification of terminal illness occurs.

Services Included in Coverage

Medicare’s hospice benefit is comprehensive, covering a wide array of services necessary for the comfort and management of the terminal illness. These services are provided by an interdisciplinary hospice team. Covered medical services include physician care and skilled nursing care, which addresses medical needs and symptom management. The benefit also provides medical equipment, such as wheelchairs and hospital beds, along with necessary medical supplies like bandages and catheters.

Prescription drugs specifically for pain control and symptom management related to the terminal illness are also covered. Beyond direct medical care, hospice coverage extends to hospice aide and homemaker services, assisting with personal care and light household tasks. Various therapies, including physical, occupational, and speech-language pathology services, are included to help maintain function and quality of life.

Additionally, the benefit encompasses medical social services, dietary counseling, and grief and loss counseling for both the patient and their family. Short-term inpatient care is covered for periods when pain or acute symptoms cannot be managed effectively at home. Short-term respite care is also included, allowing family caregivers a temporary break from their caregiving responsibilities. Services for health problems not related to the terminal illness generally continue to be covered by traditional Medicare Part A and Part B.

Beneficiary Financial Responsibilities

Medicare covers 100% of the approved costs for hospice care, meaning there are typically no deductibles or coinsurance payments for the direct hospice services. This extensive coverage aims to alleviate financial burdens during a challenging time.

While most hospice costs are fully covered, there are a few specific exceptions where a small copayment may apply. Patients might owe a copayment of up to $5 for each prescription for outpatient drugs that are provided for pain and symptom management related to the terminal illness. A small coinsurance payment, typically 5% of the Medicare-approved amount, is required for inpatient respite care. These are generally the only out-of-pocket costs associated with services directly covered under the Medicare hospice benefit. Costs for room and board in a nursing home or other facility are not covered unless the patient requires short-term inpatient or respite care.

Steps to Obtain Benefits

Initiating Medicare hospice benefits begins with a discussion between the patient and their physician. The doctor can assess the patient’s condition and determine if they meet the medical criteria for hospice care. This initial conversation helps clarify the patient’s goals of care and whether hospice aligns with those wishes.

Following this, the patient or their family needs to select a Medicare-approved hospice agency. It is important to choose a hospice provider that can meet the patient’s specific needs and preferences. Once a hospice agency is chosen, the patient’s attending physician and the hospice medical director will formally certify that the patient is terminally ill with a prognosis of six months or less.

The next step involves the patient or their legal representative signing an election statement. This document formally elects the Medicare hospice benefit, acknowledging the focus on comfort care and outlining the services covered. After the election is complete, the hospice team will conduct an initial assessment and collaborate with the patient and family to develop an individualized plan of care tailored to their unique needs and preferences.