Hospice costs, Medicare, and other coverage

For patients who meet eligibility and elect the benefit, Medicare Part A covers services related to the terminal illness and related conditions. That includes:

• Nursing care, including scheduled visits and on-call availability.
• Physician services, including the hospice medical director.
• Medications for pain relief and symptom management related to the terminal diagnosis.
• Medical equipment such as a hospital bed, wheelchair, walker, and commode.
• Medical supplies, including wound care and incontinence supplies.
• Home health aide services for personal care.
• Social work and spiritual counseling.
• Short-term respite care and general inpatient care when clinically indicated.
• Bereavement support for the family for up to a year after the death.

Medicare pays the hospice a daily rate for this care rather than paying each service separately. That is why medications and equipment arrive through the hospice rather than through your regular pharmacy or durable medical equipment supplier.

The hospice benefit has no deductible for hospice services, and generally no coinsurance for routine home care. Two narrow exceptions matter:

• Medications. You may owe a copayment of up to $5 per prescription for outpatient drugs for pain and symptom management. Many hospices absorb this; ask.
• Respite care. You may owe 5% of the Medicare-approved amount for respite care stays.

Beyond that, Medicare does not cover room and board in an assisted living community, board-and-care home, or nursing facility. It also does not cover around-the-clock attendant care in the home. If a patient lives in a facility, the facility’s charges continue to apply and are usually paid privately or through Medi-Cal.

The Medicare hospice benefit is organized into benefit periods: two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period, the hospice physician must recertify that the patient remains terminally ill.

A patient can revoke the hospice benefit at any time (for example, to pursue treatment again) and can re-elect it later if they qualify. Revoking does not permanently use up the benefit.

Medi-Cal includes a hospice benefit that largely mirrors Medicare for people who qualify. Dual-eligible patients (those with both Medicare and Medi-Cal) are generally covered for hospice services and, importantly, Medi-Cal can cover room and board in a nursing facility in some circumstances. Eligibility rules are specific; ask the hospice social worker for help.

Medicare Advantage plans must cover hospice, but the hospice itself is usually paid under Original Medicare while the plan continues to cover unrelated care. Some plans add extra services. Ask the plan what changes.

Private insurance typically includes a hospice benefit with its own rules on copays, prior authorization, and network. Ask for the summary of benefits before admission, and ask the hospice billing office to verify your coverage in writing.

• Room and board in a facility.
• 24-hour in-home attendant care or private duty nursing.
• Home modifications such as ramps or grab bars.
• Most treatment intended to cure the terminal illness.
• Care unrelated to the terminal diagnosis, which continues to be billed to your regular insurance.
• Funeral or burial costs.

Some treatments used to relieve symptoms may still be covered, along with care for conditions unrelated to the terminal illness. The hospice team and the treating clinicians can explain what is appropriate, available, and covered for an individual patient.

Families are sometimes surprised by the last few items, particularly attendant care. Hospice provides visits and phone access; it does not provide a caregiver who stays in the home all day.

We verify coverage before admission and explain what we expect insurance to pay and what may remain. We do not describe hospice as free without explaining the copayments and exclusions above.

If cost is a barrier, say so during the first conversation. There may be options: Medi-Cal enrollment, a different benefit structure, or a referral to a social worker who knows the programs available. What applies depends on the person’s coverage and situation, and it is usually clearer once someone has looked at the actual policy.