5 Common Questions and Answers About Medicare and Hospice

One of the most common questions we hear about hospice care is, “How is hospice paid for?”

The primary way families cover the cost of hospice is through Medicare Part A. In addition to Medicare, Medicaid also covers hospice in most states. There are a few important things to know about Medicare coverage for hospice care, as well as Medicaid, to help avoid any confusion or issues for the patient and/or family.

Here are some of the main areas to become familiar with related to Medicare, Medicaid, and hospice care:

1. Who qualifies for Medicare-covered hospice care?

To meet the requirements for Medicare hospice care, a patient needs to fulfill all of the following:

1. Be enrolled in and covered by Medicare Part A (Hospital Insurance)

Most qualify for the Medicare Part A benefit if they are 65 years or older or have been disabled for longer than two years. 

2. Have a terminal illness diagnosed and certified by a physician
3. Have an estimated life expectancy of 6 months or less if the illness progresses without treatment

2. What Medicare-covered services does hospice include?

Hospice care is designed to promote quality of life, pain management, and peace during a terminal illness, rather than to treat the illness. Patients in hospice care still receive expert medical attention, but the focus of hospice is holistic well-being for the patient and his or her loved ones. Medicare covers most of the benefits of hospice, including:

• Pain and symptom management
• Counseling and support services for both patients and their families, including spiritual guidance if requested
• Medications required for pain management or management of other symptoms connected to the terminal illness
• Medical equipment and supplies
• Nursing care on call 24/7
• Social work services
• Respite care to support family caregivers

Please note that coverage may not apply for prescriptions not related to the patient’s illness or those which are considered ‘curative’ (intended to cure a disease rather than relieve symptoms), and/or for respite care, that may require additional coverage or a copayment out of pocket.

It’s always encouraged to review the patient’s specific insurance plan(s) with a hospice provider to ensure you’re on the same page about what will be covered. We can help your family understand the various considerations and coverage options, should you seek our care.

3. What is Medicaid hospice care?

Medicaid hospice care is hospice care provided under the coverage of Medicaid, a health insurance program administered jointly by the federal government and each individual state. It typically covers most of the same benefits as Medicare, but because states have some flexibility in how they operate their Medicaid programs, rules, eligibility, and coverage vary state-by-state.

In addition to a terminal diagnosis with an initial life expectancy of six months or less, Medicaid may also require a patient to meet certain income or asset limits to qualify for hospice coverage. Like with Medicare, it’s important to check the rules in the patient’s state of residence and discuss what to expect with a hospice provider and/or directly with your state’s Medicaid agency.

4. Where can Medicare and Medicaid-covered hospice care be provided?

Medicare and Medicaid can cover hospice care received at a residential home, as well as in an assisted living facility, a nursing home, or – under certain circumstances – in a hospital.

The goal of hospice care is to help provide the best possible quality of life for patients and their families when experiencing a terminal illness. We know this is often best achieved when patients are in a familiar, comfortable environment that feels like home, where they and their loved ones can spend time in peace.

Wherever that place may be, there are a few additional considerations to be aware of:

• To receive Medicare/Medicaid-covered hospice care in an assisted living facility or nursing home, the facility needs a contract in place with your hospice provider. There are networks of Medicare and Medicaid-approved hospice providers to choose from, including Magnolia
• Room and board costs for facilities are generally not covered by Medicare/Medicaid.
• Hospice services received in a hospital must meet certain criteria and must be certified as necessary by the hospice provider.

5. How long will Medicare/Medicaid cover hospice?

A topic we counsel with patient families about frequently is timing of hospice care – both when to begin care as well as how long a patient can receive care. Medicare and Medicaid will cover hospice services for the duration that the patient remains eligible (see question #1).

Throughout the course of the patient’s hospice care, periodic recertification will be required to maintain covered services through Medicare or Medicaid. This means that, although the patient needs an initial terminal diagnosis with a prognosis of six months or less to begin hospice, he or she can be recertified to remain on care beyond that original six months by a hospice medical director or physician.