Medicare Fee for Service: Hospice

Hospice Coverage

Hospice is a comprehensive, holistic program of care and support for terminally ill patients and their families. Hospice care changes the focus to comfort care (palliative care) for pain relief and symptom management instead of care to cure the patient’s illness.

Patients with Medicare Part A can get hospice care benefits if they meet the following criteria:

• They get care from a Medicare-certified hospice
• Their attending physician (if they have one) and the hospice physician certifies them as terminally ill, with a medical prognosis of 6 months or less to live if the illness runs its normal course
• They sign an election statement to elect the hospice benefit and waive all rights to Medicare payments for the terminal illness and related conditions

After certification, the patient may elect the hospice benefit for:

• Two 90-day periods followed by an unlimited number of subsequent 60-day periods.
• After the second, 90-day period, the recertification associated with a hospice patient’s third benefit period, and every subsequent recertification, must include documentation that a hospice physician or a hospice nurse practitioner had a face-to-face (FTF) encounter with the patient. The FTF encounter must document the clinical findings supporting a life expectancy of 6 months or less.

All hospice care and services offered to patients and their families must follow an individualized written plan of care (POC) that meets the patient’s needs. The hospice interdisciplinary group establishes the POC together with the attending physician (if any), the patient or representative, and the primary caregiver.
 

Items & Services Included in the Hospice Benefit 

The Medicare hospice benefit includes these items and services to reduce pain or disease severity and manage the terminal illness and related conditions:

• Services from a hospice-employed physician, nurse practitioner (NP), or other physicians chosen by the patient
• Nursing care
• Medical equipment
• Medical supplies
• Drugs to manage pain and symptoms
• Hospice aide and homemaker services
• Physical therapy
• Occupational therapy
• Speech-language pathology services
• Medical social services
• Dietary counseling
• Spiritual counseling
• Individual and family or just family grief and loss counseling before and after the patient’s death
• Short-term inpatient pain control and symptom management and respite care

Medicare may pay for other reasonable and necessary hospice services in the patient’s POC. The hospice program must offer and arrange these services
 

Hospice Levels of Care

Generally, Medicare pays hospice agencies a daily rate for each day a patient is enrolled in the hospice benefit. Medicare makes this daily payment regardless of the number of services provided on a given day, including days when the hospice provides no services. The daily payment rates cover the hospice’s costs for providing services included in patient care plans. Medicare makes daily payments based on 1 of 4 levels of hospice care:

1. Routine home care: A day the patient elects to get hospice care at home and isn’t getting continuous home care. A patient’s home might be a home, a skilled nursing facility (SNF), or an assisted living facility. Routine home care is the level of care provided when the patient isn’t in crisis. 
2. Continuous home care: A day when both of these apply:
   • The patient gets hospice care in a home setting that isn’t an inpatient facility (hospital, SNF, or hospice inpatient unit)
   • The care consists mainly of nursing care on a continuous basis at home 
     
     Patients can also get hospice aide, homemaker services, or both on a continuous basis. Hospice patients can get continuous home care only during brief periods of crisis and only as needed to maintain the patient at home.
      
3. Inpatient respite care: A day the patient elects to get hospice care in an approved inpatient facility for up to 5 consecutive days to give their caregiver a rest.
4. General inpatient care: A day the patient elects hospice care in an inpatient facility for pain control or acute or chronic symptom management, which can’t be managed in other settings.

Hospice Coinsurance

Hospices may charge patients for these coinsurance amounts: 

• Drugs and Biologicals Coinsurance: Hospices provide drugs and biologicals to lessen and manage pain and symptoms of a patient’s terminal illness and related conditions. For each hospice-related palliative drug and biological prescription:
  • The patient owes a coinsurance payment when they got it during routine home care or continuous home care. The coinsurance amount is 5% of the cost of the drug or biological to the hospice, determined by the drug copayment schedule set by the hospice. The coinsurance for each prescription may not be more than $5.00. 
  • The patient does not owe any coinsurance when they got it during general inpatient care or respite care.
• Respite Care Coinsurance: The patient’s daily coinsurance amount is 5% of the Medicare payment for a respite care day. The coinsurance amount may not be more than the inpatient hospital deductible for the year that the hospice coinsurance period began. This level of care includes room and board costs. 

Hospice Quality Reporting Program 

For more information about quality data submission and reporting requirements, visit the Current Measures and Hospice Quality Reporting webpages.