The Medicare Hospice Benefit Day to Day: What It Pays For at Home

Your family said yes to hospice last week. Now you want to know what happens on a normal day. Who comes to the house? Which drugs are paid for? What does the bed in the living room cost? The Medicare hospice benefit pays for care tied to the terminal illness, given by a Medicare-approved hospice, under a plan of care your family helps to set. It does not work like a hospital stay. Care comes to you, most of it at home, in visits spread through the week. This guide walks through a normal week on the benefit, what it pays for, and the few costs that stay with you. Our /hospice/ hub holds more guides on this benefit.

Who can get the benefit

Hospice is for a person whose illness cannot be cured and who chooses comfort care over cure-based care. The hospice doctor and your own doctor, if you have one, certify that your life expectancy is 6 months or less if the illness runs its normal course (Ledger B1). You sign a statement that picks hospice care for your terminal illness. From that point, the hospice team manages the care tied to that illness.

You can stop hospice at any time and go back to cure-based care. You can also return to hospice later if you still qualify. Our guide on revoking a hospice election, posted on this site, walks through those steps.

What a normal week looks like

Care runs on a plan that the hospice team writes with you and your family. A normal week at home can include:

Visits are spread out, not round the clock. The team also gives your family a phone number that works day and night. If pain spikes at 2 in the morning, you call the hospice first. A nurse can guide you by phone or come out to the home.

• Nurse visits to check pain, breathing, and other symptoms, and to adjust the plan.
• Aide visits to help with baths, dressing, and other daily care.
• Visits or calls from a social worker, who helps with forms, family talks, and plans for the days ahead.
• Visits from a chaplain or counselor, if you want them.
• A doctor who works with the team and guides the medical side of the plan.
• Volunteers who sit with the patient so a family caregiver can rest or run an errand.

Drugs, equipment, and supplies

The benefit covers drugs for pain and symptom control tied to the terminal illness. You may pay up to $5 for each outpatient prescription of that kind (Ledger A14). Drugs for other health problems you have are not part of the hospice plan. Those still run through your normal coverage, such as Part D, with its own costs.

Equipment tied to comfort and care is covered too. A hospital bed, a wheelchair, oxygen, and supplies such as bandages can be brought to the home as part of the plan. The hospice arranges them. You do not rent them on your own if they are part of the plan of care.

Short stays away from home are covered in two cases. The team can arrange a short inpatient stay when pain or symptoms cannot be managed at home. The team can also arrange respite care, a short stay in a facility so your family caregiver can rest. A respite stay can last up to 5 days at a time, and you may pay 5 percent of the Medicare-approved amount for it (Ledger A14, A15).

What the benefit does not pay for

Original Medicare still pays for covered care for health problems that are not part of the terminal illness. That care keeps its own deductible and coinsurance rules.

• Treatment meant to cure the terminal illness, once you pick hospice for that illness.
• Drugs meant to cure the illness, rather than to control pain or symptoms.
• Room and board. If you live at home, there is no room charge. If you live in a nursing home, you or Medicaid still cover the room cost while hospice covers the care.
• Care from a provider the hospice team did not arrange, such as an emergency room visit or ambulance ride the team did not set up.

Who pays for what

• Original Medicare, through the hospice benefit, pays the hospice for care tied to the terminal illness: visits, drugs for pain and symptoms, equipment, and short stays the team arranges. You pay nothing for the hospice care itself and there is no deductible (Ledger A14).
• Medicare Advantage plans do not run hospice. Members who pick hospice get the benefit through Original Medicare, even while they stay in their plan for other care.
• A Medigap policy pays toward costs Original Medicare leaves on non-hospice care. It does not cover a service on its own.
• Medicaid can help with room and board in a nursing home for people who qualify, and can cover care outside the hospice plan under state rules.
• You and your family pay the small hospice copays: up to $5 per outpatient prescription for pain and symptoms, and 5 percent of the approved amount for respite care (Ledger A14). You also pay for care the team did not arrange.

Sample situation

Rosa is 84 and has advanced heart disease. Her doctor certifies that her life expectancy is 6 months or less, and Rosa picks hospice care at home (Ledger B1). A nurse visits twice a week. An aide helps her bathe three times a week. The hospice brings a hospital bed and oxygen to her home. Her pain drug costs her $5 at most for each outpatient prescription (Ledger A14). In the third week, Rosa's daughter, who gives most of the daily care, needs a rest. The team arranges a respite stay of four days at a local facility. Rosa pays 5 percent of the Medicare-approved amount for that stay (Ledger A14). When Rosa comes home, the visits resume on the same plan. Her family pays nothing for the hospice visits themselves, and no deductible applies (Ledger A14). On the fifth day, Rosa comes home and her daughter sleeps in her own bed again that night. Nothing about the plan changed while Rosa was away. The same nurse and aide resume their visits, and the night phone number still works the same way.

Questions families ask in the first week

Ask the team how often each visit will come, and write the plan down. Ask which number to call at night, and test it once during the day. Ask which drugs are part of the plan and which stay on your drug plan. Ask what happens if symptoms get worse on a weekend. The first week sets the pattern. A family that knows the plan, the visit days, and the night number can rest between visits. Our /hospice/ hub has more guides, including the guide on the election statement addendum posted on this site.

Sources

• https://www.medicare.gov/coverage/hospice-care