Medicare & Hospice Benefits - Getting Started

Medicare hospice benefits
Hospice is a program of care and support for people who are terminally ill. Here are some important facts about hospice:

  • Hospice helps people who are terminally ill live comfortably.
  • Hospice isn’t only for people with cancer.
  • The focus is on comfort, not on curing an illness.
  • A specially trained team of professionals and caregivers provide care for the “whole person,” including your physical, emotional, social, and spiritual needs.
  • Services may include physical care, counseling, prescription drugs, equipment, and supplies for the terminal illness and related conditions.
  • Care is generally provided in the home.
  • Family caregivers can get support.

Important: The hospice program you choose must be Medicare approved to get Medicare payment.

 If you have Medicare Part A (Hospital Insurance) AND meet these conditions, you can get hospice care:

  • Your regular doctor and the hospice medical director certify that you’re terminally ill (with a life expectancy of 6 months or less.)
  • You accept palliative care (for comfort) instead of care to cure your illness.
  • You sign a statement choosing hospice care instead of other Medicare-covered benefits to treat your terminal illness and related conditions.

Hospice care is given in benefit periods. You can get hospice care for two 90-day periods followed by an unlimited number of 60-day periods. At the start of each period, the hospice medical director and your doctor must recertify that you’re terminally ill, (with a life expectancy of 6 months or less), so you can continue to get hospice care. You have the right to change providers once during each benefit period.

You always have the right to stop hospice care at any time for any reason. If you stop your hospice care, you’ll get the type of Medicare coverage you had before you chose a hospice program (like treatment to cure terminal illness.). If you’re eligible, you can go back to hospice care at any time.

What’s covered?
Hospice care is usually given in your home. Depending on your terminal illness and related conditions, the plan of care your hospice team creates can include any or all of these services:

  • Doctor services
  • Nursing care
  • Medical equipment (like wheelchairs or walkers)
  • Medical supplies (like bandages and catheters)
  • Prescription drugs
  • Hospice aide and homemaker services
  • Physical and occupational therapy
  • Speech-language pathology services
  • Social worker services
  • Dietary counseling
  • Grief and loss counseling for you and your family
  • Short-term inpatient care (for pain and symptom management)
  • Short-term respite care - If your usual caregiver (like a family member) needs a rest, you can get inpatient respite care in a Medicare-approved facility (like a hospice inpatient facility, hospital, or nursing home). Your hospice provider will arrange this for you.
  • Any other Medicare-covered services needed to manage your pain and other symptoms that are part of your terminal illness and related conditions, as recommended by your hospice team. ? If your usual caregiver (like a family member) needs a rest, you can get inpatient respite care in a Medicare-approved facility (like a hospice inpatient facility, hospital, or nursing home). Your hospice provider will arrange this for you.

Important: Once you choose hospice care, your hospice benefit should generally cover everything you need. Original Medicare will still pay for covered benefits for any health problems that aren’t part of your terminal illness and related conditions, but this is very rare.

What do I pay?
You’ll pay:

  • A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Medicare prescription drug coverage (Part D).
  • 5% of the Medicare-approved amount for inpatient respite care.

All Medicare-covered services you get while in hospice care are covered under Original Medicare, even if you were previously in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan.

Note: If your Medicare Advantage Plan or other Medicare health plan covers extra services that Original Medicare doesn’t cover (like dental and vision benefits), your plan will continue to cover these extra services while you’re in hospice care (as long as you continue to pay your premium).

Your Medicare rights
People with Medicare have certain guaranteed rights. If your hospice program or doctor believes that you’re no longer eligible for hospice care because your condition has improved—and you don’t agree—you have the right to ask for a review of your case.

Your hospice should give you a notice that explains your right to an expedited (fast) review by an independent reviewer hired by Medicare, called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). If you don’t get this notice, ask for it. This notice lists your BFCC-QIO’s contact information and explains your rights.

You can also visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your BFCC-QIO. TTY users should call 1-877-486-2048.

Note:  If you pay out-of-pocket for an item or service your doctor ordered, but the hospice refuses to give it to you, you can file a claim with Medicare. If your claim is denied, you can file an appeal.

For more information on appeals, visit Medicare.gov/appeals or call 1-800-MEDICARE.

For information about how to file a complaint about the hospice that’s providing your care, visit Medicare.gov/claims-and-appeals/file-a-complaint/complaints.html or call 1-800-MEDICARE.

“Medicare & Hospice Benefits: Getting Started” isn’t a legal document. More details are available at Medicare.gov/publications. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings

CMS Product No. 11361
Revised February 2015