If you or a loved one has a serious health condition that has been deemed terminal, it may be time for hospice care, a type of palliative care that focuses on making the individual as comfortable as possible in their final phase of life. Entering hospice care can seem scary, and navigating both your grief and your care options can be difficult for many families as end of life looms.
It may be a relief to know that hospice care is among the many conditions and situations covered by Medicare Part A.
“Medicare Part A and Part B together are often referred to as ‘original Medicare’ or ‘traditional Medicare,'” explains Whitney Stidom, vice president of sales and operations with eHealth, Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California.
She continues, “Medicare Part A provides hospital insurance and covers a wide-range of inpatient services,” including home health services and hospice care.
The means your financial burdens may be fewer during this time of life, but there are some limitations to this coverage. Read on to learn the details about the Medicare hospice benefit.
Who Qualifies for Medicare’s Hospice Benefit?
Hospice care is meant for someone with a terminal illness who’s moved from actively treating their disease to relying on palliative interventions intended to keep them comfortable in their final days, weeks or months.
How long someone remains in hospice care can vary widely. For example, a person might have just a few days of hospice care before they pass. But as President Jimmy Carter has shown, some individuals can live a year or longer in hospice. It all depends on the person’s condition and prognosis.
To qualify for this coverage, you need to meet specific criteria. You must:
— Have Medicare Part A coverage, whether through original Medicare or a Medicare Advantage plan
— Have a terminal illness with a life expectancy of six months or less as certified by a hospice doctor and your regular doctor
— Terminate curative treatment and accept palliative care only for your ailment
— Sign a statement that reflects your choice of hospice care rather than curative treatment
If at a later date you decide to pursue additional curative treatment — perhaps a new clinical trial has been launched and you want to try that — you can opt out of hospice and seek treatment. But that terminates the hospice benefit from Medicare.
Conditions that typically qualify a person for hospice care include:
— AIDS
— Cancer
— Diabetes
— Dementia
— Heart valve disorders
— Huntington’s disease
— Stroke
[READ: How to Choose and Questions to Ask a Hospice Provider Near You]
How Long Can I Stay in Hospice Care?
Once you have met the conditions for hospice care, Medicare coverage begins. The benefit is broken into two 90-day benefit periods. At the end of the first 90-day benefit period, your doctor must recertify in a face-to-face meeting that you are still eligible for hospice. You’ll then be covered for the next 90 days.
At the end of the second 90-day period, you can receive an unlimited number of subsequent 60-day benefit periods. Your doctor will need to recertify your eligibility at the end of each 60-day period for coverage to continue.
You can stop hospice care at any time, such as if your health improves or your illness goes into remission. Your doctor might also discharge you from hospice if your life expectancy has increased to longer than six months.
If you leave hospice care, you’ll need to sign a form that lists the end date of care. Your doctor can recertify you later if your life expectancy falls to six months or less again in the future, at which point you’d be eligible for the hospice benefit again.
[READ: Don’t Let a Premature Discharge Put Your Life At Risk]
What Does Medicare Pay for in Hospice Care?
Medicare provides comprehensive coverage for services rendered in hospice care, and once you’re on the benefit, it should cover everything you need, including:
— Dietary counseling
— Doctor services
— Drugs for pain and symptom management
— Durable medical equipment for pain relief and symptom management
— Grief and loss counseling for both patient and family members
— Homemaker services and hospice aides
— Nursing care
— Physical and occupational therapy services
— Short-term inpatient care for pain or symptom management
— Social services
— Speech-language pathology services
— Up to five consecutive days of inpatient respite care at a Medicare-approved facility, offered on an occasional basis
— Other services to manage pain and symptoms as recommended by the hospice care team
Your hospice care team — which consists of your regular doctor, hospice doctor, nurse, social workers and other therapists and volunteers — will work with you and your family to develop a tailored plan to meet your palliative care needs.
[Related:How to Prepare for End of Life: Medical Care and Planning]
What Does Medicare Exclude From Its Hospice Care Coverage?
While Medicare covers a wide range of hospice services, there are some things Medicare doesn’t cover:
— Treatments or medications with curative intent or those not related to your terminal condition. If, for example, you’ve been receiving chemotherapy or radiation treatment for cancer, you’ll need to stop that treatment before entering hospice.
— Room and board if you’re receiving care in your home or if you live in a nursing home or hospice inpatient facility
— Care received from a provider who’s not part of the hospice team or that wasn’t arranged by the hospice team
— Care as a hospital outpatient (e.g., emergency room visits), care as a hospital inpatient or ambulance transportation unless it’s arranged by the hospice team or is unrelated to your terminal illness.
To avoid any surprise bills, always check with your hospice team before scheduling any doctor’s appointments or accessing other services to ensure that the provider is part of the team or that the service will be covered as part of Medicare’s hospice benefit.
You can continue taking medications that are used to treat conditions or symptoms that are not directly related to the terminal condition. For example, people in hospice care can continue to taking medication to treat high blood pressure. Such medications are typically covered under your Medicare Part D plan or Medicare Advantage if it includes a prescription drug benefit.
Are There Any Costs to Using Medicare’s Hospice Benefit?
“For most people, Medicare Part A is premium-free,” says Cindy George, a senior personal finance editor at GoodRx, a free website and mobile app that tracks prescription drug prices and provides coupons and discounts on medications.
That’s because you paid into the system during your working years. However, George notes that if you didn’t work long enough to qualify for premium-free Medicare Part A, monthly premiums in 2024 range from $278 to $505 depending on how long you paid Medicare taxes. (This range may also change in 2025.)
Most people who get care from a Medicare-approved hospice provider won’t have to pay anything for Medicare’s hospice benefit. You can check a provider’s status by asking the doctor directly or checking with your state hospice organization or state health department.
If you have Medicare Advantage, you’ll need to continue paying your monthly premium — which varies depending on the specifics of your plan — but hospice care is included and will be covered.
Out-of-pocket costs related to hospice care include:
— Prescription copayments. A copayment of up to $5 for each prescription you’re given for pain and symptom management. In rare cases, the hospice benefit might not cover a specific medication, and in those cases, your Medicare Part D plan may cover it. Ask your hospice provider to check that your prescriptions will be covered, and if there’s a medication you need that isn’t covered, ask if an alternative, covered medication is available.
— Respite care copayments. If you take advantage of the inpatient respite care benefit, you may be responsible for paying 5% of the Medicare-approved amount of this care. However, your copay can’t exceed the inpatient hospital deducible for the year.
— Deductible and coinsurance for conditions not related to the terminal illness. If you have or develop other health problems that aren’t related to your terminal condition, those are typically covered under original Medicare, but you’ll need to pay any applicable deductibles and coinsurance. In 2024, the deductible for each inpatient hospital benefit period is $1,632 before original Medicare kicks in. (This amount is projected to be $1,684 in 2025.)
— Room and board. Your living costs are not paid for by Medicare. So whether you’re living at home or in a nursing home or other facility when you opt into hospice care, you’ll still be responsible for paying for your room and board out of pocket.
You can ask your hospice provider to make a list of the services, medications and other items you use that aren’t related to your terminal illness so you’ll know which costs you’ll be responsible for and which are covered under the hospice benefit. For any item that isn’t deemed part of hospice care, your provider must include an explanation for why it’s not covered, and they must give you this list within three to five days of your request. They must also provide the list to your nonhospice providers if you request that.
Does Medicare Cover 24-Hour In-Home Hospice Care?
Medicare Part A covers 24-hour continuous hospice care in cases where it’s necessary. Also known as Continuous Home Care, or CHC, this round-the-clock care is rendered in the person’s living quarters during a time of crisis, such as when they’re in intense pain or when the primary caregiver can’t manage the situation. All Medicare-approved hospices must offer CHC.
Does Medicare Pay for Hospice in a Skilled Nursing Facility?
Medicare pays for hospice care delivered in a skilled nursing facility provided the facility has a contract with a Medicare-certified hospice to provide that care. Keep in mind that room and board are not part of the hospice benefit, so you’ll still be responsible for that cost.
What to Know About Medicare Advantage and Hospice
Medicare Advantage plans are administered by private health insurance companies that are approved by Medicare. They are a little different from original Medicare in what they cover and how they’re structured, but Medicare Advantage plans do cover hospice care.
When it’s time for hospice care, your plan must help you locate an approved provider in your area. While you’re in hospice, original Medicare kicks in to cover everything you need related to your terminal illness, even if you remain in your Medicare Advantage plan.
You can stay in your Medicare Advantage plan for as long as you continue paying your monthly premium. The plan will resume covering your health care needs on the first day of the month following your leaving hospice care, should that occur.
Maintaining your Medicare Advantage plan may make sense if you have other chronic conditions that need managing that are unrelated to your terminal illness. Many Medicare Advantage plans also include dental and vision coverage, and that benefit may be worthwhile for you even during hospice.
Costs for Medicare Advantage vary by plan and typically include monthly premiums, deductible and copayments. Read the plan details for specifics on how much it costs.
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Does Medicare Cover Hospice? originally appeared on usnews.com
