The Medicare hospice benefit provides for two 90-day benefit periods. After that, it provides for benefit periods of 60 days, with no limit on the number of benefit periods. In order for a patient to remain eligible for the Medicare hospice benefit, the patient’s condition must continue to meet the Medicare hospice eligibility criteria.
This is where many families are misinformed about the six-month Medicare hospice rule.
When Medicare states the phrase “six months or less” it is referring to the expected life prognosis of a patient to determine if the patient is eligible for the Medicare hospice benefit.
If a patient is determined to be eligible for the Medicare hospice benefit and lives beyond six months, the patient is still eligible to receive Medicare-covered hospice benefits for an additional period of 60 days. The patient must continue to meet the Medicare hospice eligibility criteria to receive additional periods of hospice benefits.
Six Months Is a Prognosis, Not a Medicare Deadline
The Medicare hospice benefit is part of Medicare Part A and provides palliative care for beneficiaries with terminal conditions.
Prior to admission to a hospice program, it is required that a physician certify that the beneficiary has a terminal condition and that the beneficiary’s condition has a expected prognosis of six months or less. The beneficiary is then entitled to elect hospice care.
Beneficiaries are permitted to choose palliative care and treatment for the condition which is Evidenced Based (coverage is not provided for the treatment of the beneficiary’s terminal condition).
It is understood that patients covered under the hospice benefit are expected to live for less than six months.
However, Medicare recognizes the fact that, a patients condition may be considered terminal, but still allow for a period of time where the patient may not experience a change in their condition. This is commonly known as a benefit period.
Medicare Hospice Benefit Periods at a Glance
Instead of placing one six-month limit on hospice care, Medicare divides coverage into benefit periods.
| Benefit period | Duration | Main requirement |
| First period | 90 days | Initial hospice eligibility and certification |
| Second period | 90 days | Recertification of continued eligibility |
| Third period | 60 days | Recertification and applicable face-to-face requirements |
| Every period after that | 60 days | Continued recertification with no preset number of periods |
The first two periods together equal 180 days. After that, the patient can move into consecutive 60-day benefit periods.
There is no preset maximum number of 60-day hospice benefit periods.
That means Medicare hospice coverage doesn’t suddenly disappear on day 181. The patient’s eligibility is reassessed and, when the requirements continue to be met, hospice coverage can continue into another benefit period.
Recertification Is What Keeps Coverage Moving Forward
The initial hospice election isn’t enough to establish eligibility forever.
As the patient moves through Medicare’s benefit periods, the hospice must continue documenting that the patient’s clinical condition supports hospice eligibility.
Certification starts the process
When a patient is admitted, the attending physicians can officially determine the patient’s condition is terminal because of the expected course of the illness.
When a patient is terminal, symptoms and complications vary, and not all patients with the same illness will have the same level of functional ability.
Because of these variations, it is not sufficient to determine if a patient is terminal based solely on the patient’s diagnosis. For example, a patient can be diagnosed with an illness that is relatively rare. Because of this rarity, an official prognosis may not be easily determined. Nonetheless, the patient may still experience a rapid decline in their condition and be terminal. It is for these reasons that a determination of terminal condition should always be based on the overall assessment of the patient rather than on the patient’s diagnosis.
Later benefit periods require recertification
Hospice care is palliative and does not cure or change the progression of an illness. Care for a given patient is time-limited to a benefit period (typically 60 or 90 days). When that time period ends, the patient’s condition is reassessed to determine if care should continue.
Relevant information at that time would include the patient’s functional status, nutritional status, and symptomatology.
Other information may include the degree of assistance required by the patient, the nature and severity of complications of the terminal condition, and the progression of the condition.
If the patient continues to meet the condition of coverage, another benefit period is provided.
Face-to-Face Encounters Begin With the Third Benefit Period
This is addressed separately due to frequent misunderstanding.
As part of their recertification process, hospice nursing practitioners and medical directors must evaluate the patient in person. Adequate clinical documentation, when combined with the correct physicians billing, assists in the provision of the hospice profession’s service.
The in person evaluation of the patient helps to determine if the patient continues to meet the criteria for the hospice benefit.
Because the purpose of the encounter is to assist in making a clinical judgement for benefit recertification, it should not be viewed as an routine administrative function.
Because the purpose of these clinical visits is to evaluate if the patient’s condition justifies continued benefit eligibility, it is understandable that the patient’s family may view these clinical visits as part of the ongoing care they receive under the hospice benefit.
Living Past Six Months Doesn’t Automatically End Hospice
Suppose that a patient, who is likely in his/her late 60s/70s, is suffering from end-stage heart failure and is continuing to decline.
The family has decided that it is time to provision the hospice benefit. Medicare uses several factors when determining benefit eligibility. The family and the patient’s medical condition fulfill the factors needed for the hospice benefit.
The patient spends the first 90 days on hospice and, upon evaluation of his/her condition, the hospice care team agrees to extend the benefit for an additional 90 days.
The patient is still declining and meets the medical necessity criteria for the hospice benefit.
The six month mark for the benefit has been met, however, as long as the patient is meeting the criteria for medical benefit necessity, there is no set limit on how long the hospice benefit can be extended.
The 6 month mark helps determine benefit eligibility; however, it does not represent the end of hospice benefit services.
Hospice May End If the Patient’s Condition Changes
Medicare allows unlimited 60-day periods of hospice coverage, but that doesn’t guarantee annual coverage.
A patient must still meet the qualifications to be eligible for hospice.
Often, a patient’s condition will improve to the point that there is not enough clinical evidence to support a diagnosis of terminal condition. In that case, the hospice is legally permitted to discharge the patient.
Improvement to the point of discharge from hospice does not prevent a patient from using hospice benefits in the future.
Should the patient’s condition once again meet the requirements of Medicare’s definition of hospice, then benefits would again be available.
A patient can also choose to leave
Patients have the right to choose or to change their choices regarding their care. Patients who are currently enrolled in the hospice benefit are free to change their minds, and can withdraw from the program at any time. They are also free to pursue treatment directed at their diagnosis and are not required to wait a set period of time in between programs.
Patients are free to re-elect the hospice benefit at a later time if they once again meet eligibility requirements. This flexibility is important to understand because a patient’s goals may change as their disease process changes. It is possible that a patient may wish to forego life sustaining treatments and pursue comfort care. Conversely, a patient may wish to pursue treatment to cure their illness, and later, elect comfort care when it is apparent that a cure is no longer attainable.
Medicare Part A Covers More Than Hospice Visits
The Medicare hospice benefit is built around a plan of care for the terminal illness and related conditions.
Depending on the patient’s needs, covered hospice services may include:
- Physician and nursing services
- Pain relief and symptom management
- Drugs related to pain and symptom control
- Medical supplies
- Durable medical equipment
- Hospice aide and homemaker services
- Social work services
- Dietary counseling
- Physical, occupational, or speech-language therapy when appropriate
- Spiritual and emotional support
- Short-term inpatient care
- Short-term inpatient respite care
- Bereavement support for the family
The exact mix of services varies because hospice isn’t supposed to look identical for every patient.
A person with advanced lung disease may need oxygen equipment and intensive symptom management. Someone with an advanced neurological condition may require a different combination of nursing care, medical equipment, personal assistance, counseling, and coordinated neurology billing for covered services.
The hospice plan of care should reflect those individual needs.
Four Levels of Hospice Care Can Be Used as Needs Change
Medicare recognizes different levels of hospice care rather than expecting every patient to remain at the same intensity of service.
Routine home care
This is the standard level for patients whose symptoms can be managed in their usual living environment.
“Home” doesn’t necessarily mean a private house. Hospice services can be delivered in other places where the patient lives when coverage requirements are met.
Continuous home care
A patient experiencing a period of crisis may need more intensive care to manage acute symptoms.
Continuous home care is intended for these short-term situations rather than routine around-the-clock caregiving.
General inpatient care
Some symptoms become difficult to manage safely or effectively in the patient’s usual setting.
General inpatient hospice care may be appropriate when pain or other acute symptoms require an inpatient level of management.
Inpatient respite care
It is common for caregivers to need a temporary break from their caregiving responsibilities.
Certain patients who meet Medicare requirements may receive up to 5 days of inpatient respite care.
Just because a patient requires a higher level of care, does not mean they would receive an additional 6 months of hospice care. Think of it as a continuum of care where patients and their families can move up and down based on the level of service they require.
During a period of increased care, the patient and their family may utilize the continuum of care for as long as the patient’s hospice benefit is available.
Most Hospice Care Has Little Patient Cost Sharing
There are some financial considerations for patients and families to be aware of for hospice care, even though Medicare normally pays the cost of hospice services.
There are copays for some prescription medications. Medicare beneficiaries may pay up to $5 per prescription for symptom management and pain management prescriptions.
The beneficiary is responsible for 5% of the Medicare approved amount for inpatient respite care.
There are other costs for services related to the hospice benefit. These costs are determined by the patient’s needs and the benefit.
It’s important for families to speak with the hospice care team to determine the costs associated with services and to understand what services are offered by hospice, to avoid financial and emotional burden of paying for services that may be provided by hospice.
Room and Board Is a Separate Issue
Misunderstandings about nursing homes and assisted living facilities are common.
Residents of nursing homes and other assisted living facilities who are eligible for hospice services can receive those services under Medicare. However, that does not mean the nursing home or assisted living facility receives regular reimbursement for room and board from the Medicare hospice benefit.
Those services can be thought of separately.
Residents of nursing homes can receive many different services under Medicare’s hospice benefit, including nursing services, medicine, and equipment.
The cost of a resident living in the nursing home is not covered by the Medicare hospice benefit.
There are a few exceptions to this rule, and financial arrangements should be reviewed before assuming that all costs for a stay in a particular facility will be covered.
Curative Treatment Isn’t Part of the Hospice Election
Electing hospice means choosing comfort-focused care instead of Medicare-covered treatment intended to cure the terminal illness and related conditions.
For example, symptom relief, pain management, and treatment designed to improve comfort may fit within the hospice plan.
Treatment being pursued specifically to cure the terminal illness generally doesn’t.
That doesn’t prevent a patient from changing their mind. A person who wants to resume curative treatment can revoke the hospice election.
The distinction is based on the goals of the treatment, which is another reason to discuss planned services with the hospice team before receiving them elsewhere.
Care Unrelated to the Terminal Illness Can Still Be Covered
Selecting hospice care does not prevent a person from accessing other Medicare services.
A person may still need medical services for conditions that are not related to the terminal condition and are separate from the conditions for which the person is receiving hospice care.
Let’s say a person on hospice care develops a condition for which the hospice care team decides is unrelated to the person’s terminal condition. The hospice team may decide that the condition is outside the hospice benefit, and that Medicare would pay for that condition and its treatment.
It is often unclear to families which conditions are related to the terminal condition.
Before assuming that the services the family wishes to arrange for the person on hospice care are unavailable, discuss your concerns with the hospice team. The hospice team will clarify whether the services are related to the condition for which hospice care is being provided, and will help the family to organize the services.
The hospice team wishes to prevent unexpected problems with the coverage of services related to the terminal condition of the person for whom hospice care has been arranged.
Medicare Advantage Doesn’t Set a Separate Hospice Time Limit
Beneficiaries are allowed to utilize both Medicare Advantage and hospice care at the same time.
Beneficiaries can enroll in Medicare Advantage and switch to hospice care when they decide to forego care for a curable illness and elect to receive hospice care. Under Medicare rules, if a beneficiary receives hospice care, then Medicare Advantage is required to provide the beneficiary the appropriate care for their illness that is within the scope of Medicare’s benefit.
A Medicare Advantage plan is allowed to cover services related to the terminal illness as well as non-terminal illness.
The services that a plan covers is at the discretion of the plan. Thus, beneficiaries should be aware of what services both the Medicare Advantage plan and the hospice service covers in order to receive the services they need.
Five Medicare Hospice Myths Worth Clearing Up
Hospice automatically ends after six months
It doesn’t. Eligible patients can continue into unlimited 60-day benefit periods after the first two 90-day periods.
If someone survives six months, they were never eligible
Living longer than initially expected doesn’t by itself prove the original hospice election was inappropriate. Prognosis is based on the expected course of an illness, not an exact prediction of the date of death.
A patient can’t change their mind after choosing hospice
Hospice can be revoked. A patient may also be able to elect hospice again later if the eligibility requirements are met.
Medicare pays the nursing-home bill once hospice starts
Medicare may pay for covered hospice services delivered to an eligible nursing-home resident, but the hospice benefit generally doesn’t pay ordinary room and board.
Hospice means giving up all Medicare coverage
The hospice election concerns care for the terminal illness and related conditions. Medicare may continue covering qualifying care for unrelated medical needs under the applicable coverage rules.
A Simple Checklist Before the Next Benefit Period
If a family member has been receiving hospice for several months, don’t wait until the final day of a benefit period to ask about continued coverage.
Talk with the hospice team and confirm:
- Which benefit period the patient is currently in
- When the current period ends
- Whether recertification has been scheduled
- Whether a face-to-face encounter is required
- Whether the patient’s clinical record supports continued eligibility
- Which medications and services are included in the hospice plan
- Which costs, if any, the patient or family may have to pay
These questions are especially useful once the patient approaches the third benefit period, when the recurring 60-day structure and face-to-face requirements become relevant.
Frequently Asked Questions
Does Medicare stop paying for hospice after six months?
No. Six months is part of Medicare’s eligibility standard, not a maximum coverage period. Medicare provides two initial 90-day benefit periods. Eligible patients can then continue through an unlimited number of 60-day periods when they remain terminally ill and the required recertification is completed.
How long can someone stay on hospice with Medicare?
Medicare doesn’t set a fixed maximum number of days for an eligible hospice patient. After the first two 90-day periods, hospice can continue through additional 60-day periods. Each new period depends on the patient continuing to meet Medicare’s hospice eligibility and recertification requirements.
Can hospice be extended after the first 180 days?
Yes. The first 180 days consist of two 90-day benefit periods. After those periods, Medicare permits additional 60-day benefit periods. There is no predetermined maximum number of these periods, but the patient must continue qualifying and meet the applicable recertification requirements.
Can a patient return to hospice after being discharged?
Yes, if the patient later meets Medicare’s hospice eligibility requirements. A person whose health improves enough to leave hospice may experience further decline later. If the terminal prognosis and other requirements are met again, the patient may be able to elect hospice again.
Does Medicare pay for hospice care in a nursing home?
Medicare can cover eligible hospice services for someone living in a nursing home. The hospice benefit generally doesn’t cover the facility’s normal room-and-board charges. Short-term inpatient hospice care and respite care have separate coverage rules when Medicare’s requirements are satisfied.
Does Medicare cover hospice medications?
Medicare’s hospice benefit covers medications used for pain relief and symptom management related to the terminal illness and related conditions. The patient may owe up to $5 for a covered outpatient prescription while at home. Medication intended to cure the terminal illness isn’t covered as part of the hospice benefit.
