Understanding hospice care and Medicare coverage

If someone in your family needs hospice care, this column explains what it is and what Medicare covers.

What is hospice care?

Hospice care is a program of care and support for patients who are terminally ill. These patients may no longer want to try to cure a terminal illness, or their doctor may have determined that efforts to cure an illness are not working. To qualify for hospice care, the patient’s regular doctor and a hospice medical director must certify that the patient is terminally ill and has six months or less to live.

A decision about hospice care can be emotionally difficult for the family, and the patient should be part of this decision whenever possible.

What is the goal of hospice care?

The goal of hospice care is to help patients who are terminally ill live comfortably. Hospice services may include physical care, counseling, drugs (including pain medication), and other treatments that can help a person feel more comfortable physically and at ease emotionally.

Hospice care can include doctor and nursing services, home health aide and homemaker services, social worker services, grief and loss counseling, and short-term care in a medical facility for pain and symptom management.

Care is generally given in the home but can also be provided at an inpatient facility.

What Medicare benefits are available for hospice care?

Medicare hospice benefits are available to patients who are eligible for Medicare Part A (hospital insurance) and who are certified as having six months or less to live (if the illness runs its normal course). Patients must sign a statement choosing hospice care instead of other Medicare-covered benefits to treat the terminal illness.

It is important to remember that Medicare will still pay for covered benefits for any health problems not related to the terminal illness. Medicare will also pay for a one-time only hospice consultation, and it will pay for this consultation even if the patient does not go into hospice care.

Once a patient is certified as having six months or less to live and has proactively chosen hospice care, Medicare covers a full package of services related to hospice care. There is no deductible or upfront amount the patient must pay before coverage begins. The copayment or charge for each prescription drug or for products for pain relief and symptom control cannot be more than $5.

All services a patient receives while in hospice care are covered under original Medicare. If the patient has original Medicare and a Medicare supplemental policy (Medigap), the Medigap policy covers copayments and charges for drugs and respite care. And the Medigap policy covers health care costs not related to the terminal illness.

What are the terms and conditions for hospice care?

Once a patient chooses hospice care, Medicare will no longer cover treatment or prescription drugs intended to cure the terminal illness. However, hospice patients always have the right to stop hospice care at any time. At that point, health care for the terminal illness and services not related to that illness are covered as usual under Medicare.

To qualify for Medicare hospice coverage, a patient must get hospice care from a certified hospice provider. Once that hospice provider is chosen, all care for the terminal illness must be given or arranged by that provider. A patient can’t get the same type of hospice care from a different provider unless the patient officially selects a new hospice provider.

Medicare does not cover room and board if a patient is receiving hospice care in the home, in a nursing home or in a hospice inpatient facility. If the hospice team determines that the patient needs short-term inpatient care (or if the patient’s caregiver needs respite services) and the hospice provider arranges the stay in a facility, Medicare will cover the ambulance transportation and stay.

Respite care for the caregiver is covered for up to five days. Respite care is temporary care provided so that a family member or friend who is the patient’s caregiver can rest or take some time off. Respite stays can be covered by Medicare more than once, but they can be provided on an occasional basis only. There may be a small copayment for the respite stay.

For more information about Medicare rights, visit Medicare.gov/appeals or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Ron Pollack is the executive director of Families USA, a national organization advocating for health care consumers.

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