What is typically covered by insurance for hospice care?

Insurance Coverage for Hospice Care

Medicare, Medicaid, and most private insurers cover hospice care when a treating physician and hospice medical director certify that the patient has a terminal prognosis of 6 months or less if the disease follows its expected course. 1

Core Coverage Requirements

Eligibility Certification

• Two physicians must certify terminal prognosis: Both your treating physician and the hospice medical director must document that you are "more likely than not" to have less than 6 months of life remaining. 1
• Written agreement required: You must sign documentation agreeing that hospice care (not curative treatments) will be used to manage your terminal illness under Medicare and most insurance plans. 1
• No DNR requirement: Despite common misconceptions, you do NOT need a "do not attempt resuscitation" order to qualify for hospice—it is actually illegal under the Patient Self-Determination Act for Medicare-funded programs to exclude patients who refuse to forgo CPR. 1

What Insurance Covers in Hospice

Symptom management and comfort care are fully covered, including: 2

• Pain medications and other symptom control drugs
• Supplemental oxygen therapy
• Medical equipment and supplies for home care
• Nursing care and home health aide services
• Physician services
• Counseling services (medical social work, spiritual counseling)
• Short-term inpatient care for symptom control
• Respite care to provide relief for family caregivers 3

Coverage Settings

Hospice care is covered in multiple locations based on patient and family needs: 1

• Home-based care (most common and preferred)
• Nursing facilities
• Hospice inpatient units
• Hospitals (for short-term symptom management)

Important Coverage Nuances

Extended Coverage Beyond 6 Months

If you survive beyond 6 months, Medicare and other insurers will continue coverage as long as you still meet enrollment criteria—the initial 6-month certification is not a "guarantee" of death within that timeframe. 1 Patients can be recertified for continued hospice benefits. 4

Medicaid Coverage

Medicaid reimbursement for hospice typically mirrors Medicare guidelines, though availability of services may vary by state and can influence care settings available for both adults and children. 1

Withdrawal Option

If your condition unexpectedly improves, you can withdraw from hospice and return to standard Medicare or insurance coverage. 1, 5

Common Coverage Barriers and Pitfalls

Non-Cancer Diagnoses Face Additional Hurdles

Patients with advanced lung disease (COPD, interstitial lung disease), heart failure, and other non-cancer terminal conditions face more difficulty accessing hospice coverage because: 1

• Prognosis is harder to determine accurately compared to cancer
• Many physicians are unaware of eligibility criteria for non-cancer patients 1, 3
• Current prognostic criteria don't accurately predict 6-month mortality for non-cancer illnesses 5, 6

Critical point: Only 35% of patients who actually died within 6 months met Medicare's proposed eligibility criteria in one study, suggesting overly restrictive interpretation limits access. 6

Underutilization Problem

Despite excellent coverage, hospice remains severely underutilized: 1, 7

• Only 61.3% of Medicare cancer patients accessed hospice in their last month of life 1
• Median length of stay is only 17.4 days, with 36% dying within 7 days of admission 1
• Only 12-15% of Medicare beneficiaries' days in the last year of life are spent in hospice 7

This represents late referrals, not coverage limitations—the barrier is physician reluctance and prognostic uncertainty, not insurance denial. 7, 3

Audit and Review Concerns

The Centers for Medicare and Medicaid Services conducts retrospective reviews that penalize hospices when patients outlive their prognosis, creating a chilling effect where providers hesitate to enroll patients unless they are clearly dying. 7 This administrative burden limits access despite technical eligibility.

Practical Recommendations

Request immediate hospice referral when your physician indicates a prognosis of months to weeks—earlier enrollment (>3 months before death) is associated with decreased aggressive end-of-life care and better quality of life. 1 Don't wait until days before death when most referrals currently occur.

For non-cancer diagnoses, specifically ask your physician about hospice eligibility criteria, as many are unaware that conditions like advanced COPD, heart failure, and dementia qualify for coverage. 1, 3