Anyone terminally ill with six months or less to live can be considered for hospice care. In almost all cases, insurance covers hospice services, whether you have Medicare or private insurance.
Hospice aims to provide comfort from pain, management of symptoms, and emotional and spiritual support when curative treatment is no longer beneficial.
It’s important to remember that if a patient’s condition improves, they can move out of hospice care with the understanding that hospice services can be reinstated when needed. Also, if a terminal patient lives longer than six months, they can continue to receive hospice services.
That said, hospice is often used as a generic term for end-of-life care, and confusion surrounds what it entails and what it covers.
Here’s a brief explanation of what’s covered depending on the type of insurance you have.
If you have Medicare
To receive Medicare benefits for hospice care, your doctor must certify you’re terminally ill. You must also sign a statement saying you will accept comfort care instead of care to treat or cure your illness. During hospice care, you can still be treated for other health conditions that aren’t terminal.
You can choose curative care instead of hospice if you prefer. If so, you’ll need to give the hospice agency a signed, dated statement confirming that you’re revoking hospice care. You can still receive hospice care in a future period if you’re deemed eligible.
Under Medicare, there are no copayments for most hospice services. There are, however, small copayments for prescription drugs for pain relief and symptom control and for respite care (discussed later).
Under Medicare regulations (and most insurers), hospice services include the following:
- pain and symptom management
- 24-hour on-call service
- in-person visits
- medical equipment
- related medications
- inpatient care to manage acute bouts of pain
- continuous care in the home
- volunteer services
- spiritual care
- bereavement and counseling services
- art and music therapies.1
Family and caregivers get help too. Medicare provides for respite care, during which a patient may be temporarily admitted to a hospice facility or hospital, to provide a break for the caregiver. There may be a small copayment.
IMPORTANT: To ensure you receive all of the available benefits, you need to meet these criteria: your Medicare-approved doctor must certify that you’re terminally ill, and you must sign a statement saying that you choose hospice care instead of other benefits to treat your terminal illness as well as any related conditions. In addition, make sure your chosen hospice agency is Medicare-certified.2
If you have Medicare Supplement (or Medigap) Insurance
Medicare Part A covers hospice care with small copayments for pain-relief medications and respite care mentioned above. Most Medicare Supplement Insurance policies, commonly called Medigap, cover the copayments for pain-relief medications and respite care.
If you have Medicare Advantage
If you need hospice and have a Medicare Advantage Plan, your plan can help you find a hospice provider that is Medicare-certified. The hospice benefit is covered under Original Medicare. Medicare Advantage doesn’t cover hospice, so it’s provided through Original Medicare during the hospice period.
If you choose hospice care, your Medicare Advantage plan will continue to cover health care services unrelated to the terminal illness. You can also choose providers not in the plan’s network who will bill Original Medicare, and you will be responsible for cost-sharing under Original Medicare.3
If you leave hospice care, your Medicare Advantage Plan will revert to your primary coverage beginning on the first of the following month.4
If you have private insurance
Most private insurance plans cover the full cost of hospice care and define it and its accompanying services under the same guidelines as Medicare. Unlike Medicare, however, each may have unique requirements a patient must meet before hospice care is approved. Moreover, patients with private insurance may encounter different out-of-pocket costs for certain aspects of hospice care.
Every plan is different. So contact your private insurer to determine exactly what’s covered and what costs you may have.5
One caveat: No matter what your coverage, choosing high-quality hospice care can be challenging. Growth in the for-profit side of the industry has led to troubled providers with faulty management entering the field. The result can be large gaps in service, inadequate care, and even outright fraud. The Office of the Inspector General released a government report in 2019 documenting lapses in care and fraudulent schemes. Be sure you thoroughly research a hospice provider before you sign up.6