Key takeaways
- Medicare provides a hospice benefit for individuals diagnosed with an end stage illness, shifting the focus from curative treatments to providing comfort and supportive end-of-life care.
- While Medicare pays hospice care professionals directly and typically does not require a deductible for hospice care, individuals may still incur costs for certain medications and hospital treatments that are needed during hospice care.
- To qualify for Medicare’s hospice benefit, a physician must certify that the individual has a life expectancy of 6 months or less. However, the coverage can be extended if a doctor recertifies the need for continued care.
Hospice care provides support for people approaching the end of their lives as well as support for their families.
A hospice program changes the focus of treatment. Healthcare professionals no longer actively work to resolve a person’s medical condition. Instead, they focus on providing comfort and supportive care to individuals nearing the end of their lives.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Hospice coverage can vary according to a person’s unique situation. The key aspect is that hospice care represents a shift from curative to comfort-oriented treatments.
As a result, once someone uses their hospice benefit, Medicare may no longer cover doctors’ visits or medications aimed at treating the condition.
To receive hospice care benefits from Medicare, a person must meet the following criteria:
- A medical doctor and hospice doctor must certify that a person is terminally ill and likely to live for no more than 6 months.
- A person must accept palliative care, which provides comfort rather than care aimed at curing or treating their illness.
- The insured person must sign a statement indicating their desire to receive hospice care instead of other Medicare-covered treatments for their condition.
Here is how Medicare covers hospice care, according to the Centers for Medicare & Medicaid Services (CMS):
- With Original Medicare (parts A and B), Part A covers the cost of hospice.
- Medicare Part D may cover the cost of medications if Part A denies coverage for any reason.
- A Medicare Advantage (Part C) plan may cover the cost of any additional comfort or support medications or treatment that Part A does not already cover.
- Medigap may help cover the cost of deductibles or other non-covered costs, but it does not specifically cover long-term care costs.
Medicare will directly pay the healthcare professionals providing a person’s hospice care. When an individual enters a hospice program, they do not have to meet a deductible for hospice care.
However, some associated costs apply. These include:
- monthly premiums for Medicare parts A (if applicable) and B
- a copayment of up to $5 for prescription pain medications or other medications to manage discomfort
- a 5% coinsurance of the Medicare-approved amount for inpatient respite care
If a person’s condition requires hospital treatment while receiving hospice care, the hospice organization must make the necessary arrangements. This is important, as the healthcare professionals providing the hospice care will pay the hospital directly.
A person can activate hospice care when they have a life expectancy of no more than 6 months. If they live longer than this, a person’s doctor can recertify that they are terminally ill and need continued care.
A person also has the right to stop hospice care at any time if they wish to do so.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Hospice care can significantly reduce hospital stays and trips to the emergency room that someone may otherwise experience as they approach the end of their life.
Medicare pays for this to provide as much comfort and peace as possible to people with end stage health conditions as they near the end of their life.
Once coverage for hospice care begins, coverage for standard treatment no longer applies.