Medicare Coverage of Hospice Services
Hospice services are covered under Medicare Part A (Hospital Insurance), requiring patients to waive their regular Medicare Part A benefits for their terminal illness and elect the Medicare Hospice Benefit instead. 1, 2
Eligibility Requirements for Medicare Hospice Coverage
- Terminal illness certification: Patient must be certified as having a terminal illness with a life expectancy of 6 months or less if the disease runs its normal course 2, 3
- Patient election: Patient must formally choose hospice care instead of standard Medicare-covered treatments for their terminal illness 1
- Provider requirements: Care must be provided by a Medicare-approved hospice program 2
What the Medicare Hospice Benefit Covers
The Medicare Hospice Benefit provides comprehensive services including:
- Physician services and nursing care
- Medical equipment and supplies
- Medications for symptom management and pain relief
- Short-term inpatient care for symptom management
- Home health aide and homemaker services
- Medical social services
- Dietary counseling
- Grief and loss counseling for patient and family 2, 3
Settings for Hospice Care Delivery
Medicare covers hospice in various settings:
- Home-based hospice (most common)
- Inpatient hospice facilities
- Nursing homes and long-term care facilities
- Dedicated hospice units within hospitals 2
Duration and Limitations of Coverage
- Initial coverage period: Two 90-day benefit periods
- Followed by: Unlimited number of 60-day benefit periods
- Total maximum coverage: Not limited to 6 months as commonly misunderstood, but can continue as long as the patient remains eligible with physician recertification 2, 3
- Per capita spending limit: Originally set at $6,500 but has been adjusted over time 3, 4
Financial Considerations
- No cost or minimal cost to patients: Medicare pays the hospice provider directly
- Patient responsibility: May have small copayments for medications (typically $5 or less)
- Coverage structure: All-inclusive per diem rates that favor home care 3
- Cost-effectiveness: Research shows hospice care is generally less expensive than traditional end-of-life care for Medicare 5
Common Pitfalls and Considerations
- Late referrals: Nearly 30% of hospice patients are referred in the last week of life, limiting the full benefits of hospice services 1
- Live discharge: Some patients experience slower decline than expected, resulting in "live discharge" from hospice when they no longer meet eligibility criteria 6
- Misconceptions: Many believe hospice is only for the final days/hours of life, when in fact earlier referral provides greater benefits 1
- Waiving curative treatment: Patients must understand that by electing hospice, they waive Medicare coverage for treatments intended to cure their terminal illness 1, 2
- Underutilization: Hospice is often underutilized for non-cancer diagnoses despite eligibility 2
Hospice vs. Palliative Care Coverage
- Hospice: Requires terminal diagnosis, covered under Medicare Part A
- Palliative care: Can be provided alongside curative treatment, does not require terminal diagnosis, typically covered under regular Medicare Part B (not the hospice benefit) 2