How Much Does Medicare Pay for Hospice Care?

Medicare’s hospice benefit offers comprehensive support for individuals facing a terminal illness, focusing on comfort and quality of life rather than curative treatments. This care provides physical, emotional, and spiritual support to patients and their families. Medicare covers a substantial portion of these costs. This article details what Medicare’s hospice benefit includes, potential patient costs, and how to access these services.

Eligibility for Medicare Hospice Benefits

To qualify for Medicare’s hospice benefit, an individual must meet specific criteria. A primary requirement is a certification by a physician that the individual has a terminal illness with a prognosis of six months or less to live, should the illness run its expected course. This certification must come from both the individual’s attending physician, if they have one, and a hospice physician.

Acceptance of palliative care, which focuses on comfort and symptom management, is another condition for eligibility. This means the individual chooses to forgo curative treatments for their terminal illness, shifting the focus to enhancing their quality of life. The individual must then sign a statement confirming their choice of hospice care over other Medicare-covered treatments for their terminal illness and related conditions.

Medicare Part A coverage is a prerequisite for accessing the hospice benefit. While hospice care is typically associated with a six-month prognosis, individuals can continue to receive benefits beyond this period if a physician recertifies their terminal illness. This recertification process ensures continued eligibility and appropriate care as long as it is needed.

The initial certification can be completed up to 15 days before hospice care begins, providing time for planning. After the initial period, recertifications are necessary to continue benefits, ensuring ongoing medical oversight of the patient’s condition. The hospice medical record must contain clinical information and documentation supporting the prognosis.

Services Medicare Covers

Once an individual is eligible for Medicare hospice benefits, the program covers a wide range of services and items designed to provide comfort and support. These include:

Physician services, ensuring medical oversight and management of the patient’s condition.
Nursing care, offering skilled assistance with symptom management and personal care needs.
Medical equipment, such as wheelchairs, walkers, and hospital beds, to support comfort at home.
Necessary medical supplies, including bandages, catheters, and other disposable items.
Prescription drugs for pain relief and symptom control related to the terminal illness.
Hospice aide and homemaker services, assisting with daily activities and light household tasks.
Therapies, including physical, occupational, and speech-language pathology services, to maintain functional abilities.
Social worker services providing emotional and practical support, and dietary counseling.
Grief and bereavement counseling for the patient and family, during and after the hospice period.
Short-term inpatient care for acute pain or symptom management that cannot be controlled at home.
Respite care, providing temporary relief for family caregivers for up to five days at a time.

Patient Costs and Non-Covered Services

Medicare’s hospice benefit is designed to minimize financial burdens for patients and their families. Generally, Medicare covers 100% of the cost for hospice care when provided by a Medicare-approved hospice agency. This comprehensive coverage means individuals typically pay nothing for most hospice services.

There are two primary instances where a patient might incur a small out-of-pocket cost. A minimal copayment, typically no more than $5, may apply for each prescription drug used for pain and symptom management. Additionally, a 5% copayment is required for inpatient respite care.

There is no deductible for hospice care. The hospice provider bills Medicare directly, eliminating the need for patients to submit claims.

Certain services are not covered. Curative treatments for the terminal illness are explicitly excluded, as the benefit focuses on comfort care. Care provided by individuals or facilities not arranged by the hospice team is also generally not covered. Room and board costs are typically not covered if the patient receives hospice care in their home or a long-term care facility, unless part of a short-term inpatient stay for symptom management or respite care. Emergency care not coordinated by the hospice team may also result in out-of-pocket expenses.

Electing and Managing Hospice Benefits

Accessing Medicare’s hospice benefits involves selecting a Medicare-approved hospice provider. It is important to choose an agency that can meet the patient’s specific needs and preferences. Hospice care can be delivered in various settings, including the patient’s home, a nursing home, a dedicated hospice facility, or a hospital.

The hospice benefit operates in specific benefit periods. Initially, an individual is eligible for two 90-day benefit periods. Following these, an unlimited number of 60-day benefit periods can be accessed, provided the patient continues to meet the eligibility criteria. Each new benefit period requires a physician to recertify that the patient remains terminally ill.

Patients can change their hospice provider once during each benefit period. If an individual decides to pursue curative treatment or no longer desires hospice services, they can revoke their hospice benefit at any time. Revoking the benefit means returning to standard Medicare benefits for curative care.

Should circumstances change, and the individual again meets the eligibility criteria, they can re-elect hospice care at a later date. The hospice team works with the patient and family to develop an individualized plan of care that addresses their unique needs.