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How Original Medicare Covers Hospice Care (Part A)

For those with Original Medicare, hospice care is a core benefit covered under Part A, the hospital insurance portion. This benefit is designed to provide comprehensive, compassionate care for individuals who are terminally ill. To qualify, a person must meet two primary conditions. First, their regular doctor and a hospice doctor must certify that they have a terminal illness with a life expectancy of six months or less if the disease runs its normal course. Second, the individual must sign a statement choosing hospice care over other Medicare-covered treatments for their terminal illness. This means they are formally shifting the goal of care from curing the illness to providing comfort, also known as palliative care. Once the benefit is elected, Medicare Part A covers a wide range of services to manage symptoms and support the patient and their family. This includes physician and nursing services, medical equipment like a hospital bed for the home, medical supplies, prescription drugs for pain and symptom management, various therapies, and short-term respite care to provide a break for family caregivers. It also includes grief and loss counseling for both the patient and their family, which can be an invaluable source of support. It's just as important to understand what is not covered. Medicare will not pay for treatments or medications intended to cure the terminal illness, nor will it cover room and board if the person resides in a nursing home or hospice facility.

The Role of Medicare Advantage Plans in Hospice Care

If you have a Medicare Advantage (Part C) plan, the way hospice is handled has evolved. For many years, if an Advantage plan member elected the hospice benefit, their coverage would revert back to Original Medicare for all hospice-related services. However, this has changed. Now, Medicare Advantage plans are required to cover hospice care directly.

What does this mean for you? The core set of required hospice benefits remains the same, whether you have Original Medicare or Medicare Advantage. Federal law mandates that all Medicare-certified hospices provide a specific package of services. However, with an Advantage plan managing the benefit, there are a few administrative differences. Your plan will be the one paying the hospice provider. While you still have the right to choose any Medicare-certified hospice provider you wish, it can be helpful to see which providers are considered in-network with your plan for ease of administration.

Importantly, your Medicare Advantage plan still remains responsible for covering all of your medical needs that are not related to your terminal illness. For example, if a woman from Akron with an Advantage plan is on hospice for end-stage heart failure and she falls and breaks her wrist, her Advantage plan would cover the emergency room visit, x-rays, and cast for her broken wrist. The hospice team would continue to manage her heart failure symptoms. These parallel coverage tracks ensure you continue to receive all necessary medical care.

Understanding Your Out-of-Pocket Costs with Hospice

When a family is considering hospice, financial concerns are often a major source of stress. The Medicare hospice benefit is designed to alleviate much of that burden. Under Original Medicare, there is no deductible for hospice care, and the services themselves are provided with no out-of-pocket cost. This means the visits from nurses, aides, social workers, and counselors are all fully covered.

However, there are two potential, minor costs. You may have a copayment of up to $5 for each prescription drug prescribed for pain relief and symptom management while you're at home. Additionally, if your caregiver needs a break and you receive inpatient respite care, you might pay 5% of the Medicare-approved amount for that stay. For example, if Medicare approves $200 per day for respite care, your share would be $10 per day. Many Medicare Supplement (Medigap) plans cover these small cost-sharing amounts.

For Medicare Advantage members, the out-of-pocket costs for hospice cannot be higher than what you would pay under Original Medicare. Plans may have different copayments or coinsurance structures, but federal rules cap them at the Original Medicare levels for hospice services. The most significant cost that catches families by surprise is room and board. If a person lives in a nursing home or assisted living facility, Medicare pays for the *hospice services*, but it does not pay for the daily cost of living in that facility. This is a separate, private expense that the family is responsible for.

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Choosing a Hospice Provider in Northeast Ohio

The decision of which hospice agency to use is a personal one, and it belongs to the patient and their family. In Northeast Ohio, we have many compassionate, high-quality hospice providers, and your insurance plan does not get to make this choice for you. While the core medical services are mandated by Medicare, agencies often differ in their approach and the additional support they offer.

When comparing providers, consider asking about their staff-to-patient ratios, the consistency of the care team, and their 24/7 availability for urgent needs. Some hospices have unique programs, such as music or art therapy, pet therapy, or specialized veteran support programs. A family caregiver in Mentor, for example, might want to ask a prospective hospice about the specifics of their respite care program and the frequency of home health aide visits.

Your hospital's discharge planner, like those at Summa Health or the Cleveland Clinic, can be a great resource for a list of local, certified agencies. You can also get unbiased information from the state. The Ohio Senior Health Insurance Information Program, or OSHIIP, offers free counseling and can help you understand your rights and options. Ultimately, it's wise to interview two or three agencies to find the one whose philosophy of care best aligns with your family's wishes and values. This is not about finding the 'best' one, but the right one for your loved one's final chapter.

What if You Need Care Longer Than Six Months?

A common point of anxiety is the six-month prognosis required to begin hospice. Many people wonder what happens if a loved one lives beyond that initial timeframe. The Medicare system is set up to handle this with what are called 'benefit periods.'

Hospice coverage begins with two 90-day benefit periods. At the end of that 180-day stretch, if the patient is still living, the hospice medical director can re-evaluate their condition. If the doctor re-certifies that the patient is still terminally ill, they can then begin receiving care in an unlimited number of 60-day benefit periods. As long as the medical criteria are met at the beginning of each period, a person can remain on hospice care indefinitely. There is no lifetime limit on the number of days you can receive hospice care.

Occasionally, a person's health stabilizes or even improves while on hospice. In these cases, they can be discharged. This is sometimes called 'graduating' from hospice. When this happens, their regular Medicare coverage is reinstated, and they can once again seek curative treatments. If their health declines again in the future, they have the right to re-elect the hospice benefit without penalty.

Every family's situation is unique, and these rules can feel complicated during a stressful time. For clear, specific guidance on how your plan works and what to expect, use the form on this page to request a call back from our team.