The purpose of hospice is to provide comfort care and maintain a high quality of life for people who are dying. Hospice providers focus on addressing a terminally ill person’s physical, emotional, and spiritual needs in lieu of curative treatment. If a senior is eligible for Medicare, their end-of-life care is likely covered.
Medicare requirements for hospice coverage
- The senior must have Medicare Part A (hospital insurance).
- A hospice medical director (and the senior’s regular doctor, if they have one) must certify that the senior is terminally ill and has a life expectancy of six months or less.
- The senior (or their legal guardian) must elect palliative care instead of Medicare-covered benefits intended to treat their terminal illness and other related conditions and sign a statement attesting to such.
- Care must be provided by a Medicare-approved hospice provider.
What hospice services does Medicare cover?
Hospice providers offer comprehensive services that benefit both the patient and their family members. It’s important to understand that the following services may be part of a patient’s plan of care and are covered at least in part by Medicare.
- Doctor, nursing, and counseling services
- Durable medical equipment and medical supplies such as wheelchairs, walkers, or catheters
- Prescription drugs for symptom control or pain relief
- Dietary counseling
- Aide and homemaker services
- Physical and occupational therapy services
- Short-term inpatient respite care and care for pain and symptom management
- Any other Medicare-covered services recommended by the hospice team
Does Medicare cover hospice for dementia?
As long as a patient is eligible for Medicare, Medicare will typically pay for hospice care services for people who have dementia, according to the Centers for Medicare & Medicaid Services (CMS). However, there are some caveats you need to be aware of.
In order to be eligible for hospice for dementia, your loved one must meet both of the following criteria, according to the CMS:
- Your loved one must be at or beyond stage 7 of dementia. This means their dementia causes them to struggle with the following:
- Walking, dressing, or bathing without assistance
- Urinary or fecal incontinence
- Inconsistent or very limited verbal communication
- Other illnesses, also known as comorbidities, exist alongside their dementia, and they’ve received treatment for such illnesses in the last year. These comorbidities may include severe weight loss, pressure ulcers, pneumonia, sepsis, and high fever.
Note that all hospices can provide care for your loved one with dementia. However, there are certain hospice providers that specialize in dementia care and typically offer tailored programs designed to support the whole family through the unique challenges of dementia.
Read: Hospice Care for Dementia: When Is It Time?
Hospice respite care for family caregivers
Caring for a seriously ill loved one, especially someone who is nearing the end of their life, is a physically and emotionally taxing job. One of the most helpful hospice services that Medicare Part A covers is short-term inpatient respite care. This service allows a terminally ill person to continue receiving hospice care at a Medicare-approved hospice house, skilled nursing facility, or hospital so their family caregiver can rest and recuperate. Inpatient respite may last up to five days and there may be a small copayment required for the patient’s room and board during their stay. A patient and their family may request respite more than once, but this service can only be provided on an occasional basis.
Does Medicare cover 24-hour hospice care?
Medicare Part A hospital insurance can help cover the cost of 24-hour hospice care. Because it's rare, continuous, or 24-hour, hospice care can usually only be obtained in the case of an urgent need for help managing end-of-life symptoms.
Keep in mind that Medicare Part A is hospital-only insurance, so it doesn’t provide coverage for care received in the home. Part A can, however, provide some coverage for doctors and nurses who can be on-call day and night. Additionally, Part A can cover the cost of short-term inpatient care or respite care for in-home care patients whose family needs more help.
As you talk with the hospice provider about your loved one’s care needs, they’ll be able to walk you through what necessary services and equipment are covered and what aren’t.
Hospice services Medicare doesn’t cover
If a Medicare beneficiary qualifies for and elects to receive hospice care, the following items and services will not be covered.
Treatment intended to cure a terminal illness
If a senior decides to receive curative treatment for their terminal illness, then hospice care is no longer covered. Patients have the right to withdraw from hospice care at any time. They may also resume hospice care at any time as long as they still meet all eligibility requirements.
Prescription drugs to cure the terminal illness
Only drugs intended for pain relief and symptom control are covered by the Medicare hospice benefit.
Care from any hospice provider that wasn’t arranged by the hospice medical team
All care must be given or arranged by a single hospice medical team of the patient’s choice. A senior can't get the same type of hospice care from a different provider unless they officially change their selected Medicare-approved hospice provider. However, a patient may still see their regular doctor or nurse practitioner if they've been appointed to supervise the patient’s hospice care.
Room and board
Medicare doesn't cover room and board for hospice patients who live at home, in nursing homes, in assisted living facilities, or in inpatient hospice houses. Room and board is only covered during short-term inpatient or respite care stays.
Emergency care
Transportation by ambulance, care a patient receives in an emergency room, and care received as a hospital inpatient are not covered by Medicare’s hospice benefit unless these services are arranged by the patient’s hospice medical team or unrelated to their terminal illness.
Medicare and hospice cost breakdown
Most Medicare beneficiaries pay little to nothing for hospice care. Original Medicare (Parts A and B) will cover everything a patient needs related to their terminal illness, even if they're enrolled in a Medicare Advantage Plan (Part C) or have a Medigap (Medicare Supplement Insurance) policy.
If a senior on hospice wishes to remain enrolled in their Advantage Plan and make use of medical benefits and services unrelated to their terminal illness, then they will need to continue paying their premiums. Medigap policies typically provide additional coverage for things like prescription drugs and respite care for patients while they are receiving hospice care.
In some situations, the following small out-of-pocket copays may be necessary for certain items and services.
Prescription copays
A patient will pay no more than $5 for each prescription drug and other similar products they need for pain relief and symptom control. If a specific medication isn't covered by the hospice benefit, the hospice provider will contact the patient’s Part D prescription drug plan to inquire about covering it.
5% of the Medicare-approved cost for inpatient respite care
Medicare negotiates fixed rates (Medicare-approved costs) with doctors and suppliers who accept assignment. For example, if the approved cost is $100 per day for inpatient respite care, then the patient will only be responsible for paying $5 per day.
How long will Medicare pay for hospice care?
Hospice care is for patients who have six months or less to live. However, estimating someone’s life expectancy isn’t an exact science. Therefore, the Medicare hospice benefit is broken down into two 90-day benefit periods that are followed by an unlimited number of 60-day benefit periods (if needed).
A terminally ill patient can continue receiving covered hospice care as long as their hospice physician continues to certify that they have six months or less to live. Some people retain their terminal status yet survive much longer than expected and remain under hospice care for many months or even years.
A patient must be certified as having six months left to live before the services can begin and be recertified at the start of each new benefit period. A face-to-face meeting with a hospice doctor is required prior to the start of their third benefit period (day 180 of hospice) to recertify their eligibility. These face-to-face recertification meetings are then required prior to each subsequent 60-day benefit period and must take place no earlier than 30 days before the new benefit period begins.
Due to the ongoing COVID-19 pandemic, the CMS has temporarily eased some regulations, allowing telehealth services to be used in place of face-to-face encounters, including hospice recertification visits, where appropriate. This went into effect in 2020, and has been extended through April 11, 2023. This flexibility in hospice recertifications will eventually end after the conclusion of the COVID-19 public health emergency.
Finding support in a difficult time
As you plan for your loved one’s end-of-life care, it can help to have someone to lean on. By joining AgingCare’s Caregiver Forum, you can connect with other family caregivers who understand exactly what you’re going through and can offer their support, guidance, and comfort.
Reviewed by Certified Elder Law Attorney Letha McDowell.
Sources:
Hospice Care (https://www.medicare.gov/coverage/hospice-care)
How hospice works (https://www.medicare.gov/what-medicare-covers/what-part-a-covers/how-hospice-works)
42 CFR § 418.22 - Certification of terminal illness. (https://www.law.cornell.edu/cfr/text/42/418.22)
COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf)
Medicare and Medicaid Benefits for People with Dementia (https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/Outreach-and-Education/pdf/medicare-and-medicaid-benefits-for-people-with-dementia_909455-N.pdf)
Medicare hospice benefit guidelines for determining prognosis in dementia (https://www.uptodate.com/contents/image?imageKey=NEURO%2F89837)
Hospice: CMS Flexibilities to Fight COVID-19 (https://www.cms.gov/files/document/hospice-cms-flexibilities-fight-covid-19.pdf)
Federal Public Health Emergency Updates for 2023 (https://www.asha.org/news/2023/federal-public-health-emergency-updates-for-2023/)