The Medicare Hospice Benefit, Explained
Quick answer: The Medicare hospice benefit is a Part A benefit that pays for palliative care for a person certified as terminally ill, defined at 42 U.S.C. 1395x(dd)(3)(A) as a medical prognosis of six months or less if the illness runs its normal course. The patient elects hospice and waives Medicare payment for curative treatment of the terminal condition.
Current as of August 2026.
Hospice under Medicare is not a place. It is a defined package of services, listed at 42 CFR 418.202, delivered under a written plan of care. Its statutory basis is section 1861(dd) of the Social Security Act, and the operating rules are in 42 CFR Part 418. Two features set it apart from every other Medicare benefit: the patient must choose it in writing, which is called election, and choosing it means giving up Medicare payment for treatment aimed at curing the terminal condition. Everything else follows from those two facts.
Who is eligible
42 CFR 418.20 sets two requirements, and both must be met: entitlement to Medicare Part A, and certification as terminally ill under 42 CFR 418.22. Under 42 U.S.C. 1395f(a)(7), for the first 90 day period the attending physician and the hospice medical director (or the physician member of the hospice interdisciplinary group) each certify the prognosis in writing. For later periods the hospice physician alone recertifies.
42 CFR 418.22(b) says what the certification must contain: a statement that life expectancy is six months or less if the illness runs its normal course, supporting clinical information filed in the medical record, and a brief narrative from the physician that must reflect the individual patient and may not consist of check boxes or standard language used for every patient. A certification may be completed no more than 15 calendar days before the effective date of the election.
The six month figure is a prognosis, not a deadline. Nothing in Part 418 cuts off care at six months. A patient who lives longer stays on the benefit as long as a physician can still certify the prognosis at each recertification.
Benefit periods and recertification
42 CFR 418.21 divides hospice coverage into election periods: an initial 90 day period, a subsequent 90 day period, and then an unlimited number of subsequent 60 day periods. The same structure appears in the statute at 42 U.S.C. 1395d(a)(4) and 1395d(d)(1). The periods run in that order.
Under 42 CFR 418.24(f), one election continues through all of those periods without a break, as long as the patient stays with the hospice, does not revoke, and is not discharged. Families often expect to re-enroll every 90 days. They do not. The paperwork that repeats is the hospice's.
Beginning with the third benefit period, 42 CFR 418.22(a)(4) requires a face to face encounter by a hospice physician or hospice nurse practitioner before each recertification. The encounter must occur no more than 30 calendar days before the period starts, and its clinical findings must be reflected in the recertification narrative.
The election statement
Election is the act that starts the benefit. 42 CFR 418.24(a) allows the individual, or a representative if the individual is incapacitated, to file an election statement with a particular hospice. 42 CFR 418.24(b) lists what it must contain:
- Identification of the hospice and of the attending physician, with the patient's acknowledgment that the attending physician was their own choice.
- Acknowledgment that the patient has been given a full understanding of the palliative rather than curative nature of hospice care.
- Acknowledgment that certain Medicare services are waived by the election.
- The effective date, which may be the first day of hospice care or later, but never earlier than the date of the statement.
- Cost sharing information, notice of the right to request the election statement addendum, and contact information for the Beneficiary and Family Centered Care Quality Improvement Organization.
- The signature of the individual or representative.
If the hospice decides an item, service, or drug is unrelated to the terminal illness and so not covered, the patient or a non-hospice provider may request a written list. 42 CFR 418.24(c) titles that document "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" and requires a plain language clinical explanation of why each item is considered unrelated. Under 42 CFR 418.24(d) the hospice must provide it within five days if requested in the first five days of the election, and within three days later. This is where coverage disagreements surface in writing.
What the election waives
42 CFR 418.24(g) is the provision families most need explained. For the duration of the election, the individual waives all rights to Medicare payment for hospice care from any hospice other than the designated one, and for services related to treating the terminal condition or a related condition, or equivalent to hospice care.
Three things are carved out: services from the designated hospice, services from another hospice under arrangements it makes, and services from the patient's attending physician if that physician is not employed or compensated by the hospice.
The waiver is tied to the terminal condition, not to the person. Coverage continues for conditions genuinely unrelated to the terminal illness, though 42 CFR 418.24(b)(3) requires that for elections on or after October 1, 2020, patients be told that unrelated services are exceptional and unusual.
The four levels of care
Medicare pays a daily rate that varies by level of care. The four categories are defined at 42 CFR 418.302(b), with the coverage rules at 42 CFR 418.204.
| Level of care | Where | What triggers it | Key limit in the rules |
|---|---|---|---|
| Routine home care | Wherever the patient lives, including a nursing facility | The default on any day the patient is not receiving continuous care and is not an inpatient | No limit. Days in the last seven days of an election ending in death may qualify for a service intensity add-on |
| Continuous home care | The patient's home | A period of crisis requiring continuous care to manage acute symptoms and keep the patient at home | Predominantly nursing care, minimum eight hours in a day, under 42 CFR 418.302(e)(4) |
| Inpatient respite care | An approved inpatient facility | Short term relief for family or others caring for the patient | Occasional only, not more than five consecutive days, under 42 CFR 418.204(b). The sixth day pays at the routine rate |
| General inpatient care | An approved inpatient facility | Pain control or acute or chronic symptom management that cannot be managed elsewhere | Inpatient days, general and respite combined, capped at 20 percent of total hospice days under 42 CFR 418.302(f) |
Level of care is a clinical determination made by the hospice team, not a menu item. Knowing the definitions lets a family ask the right question, which is usually whether the current symptoms meet the crisis standard for continuous home care.
What the benefit covers
42 CFR 418.202 lists the covered services: nursing care supervised by a registered nurse; medical social services; physicians' services; counseling, including dietary and bereavement counseling, for the patient and caregivers; short term inpatient care; medical appliances, supplies, drugs, and biologicals used primarily for pain relief and symptom control related to the terminal illness; hospice aide and homemaker services; physical, occupational, and speech language therapy; and any other service in the plan of care that is reasonable and necessary for palliation of the terminal illness.
42 CFR 418.204(c) makes bereavement counseling a required hospice service that is not reimbursable, so the hospice must offer support to the family after the death and cannot bill for it.
What it does not cover
Medicare's beneficiary materials state the exclusions plainly, and they track the regulations. Once the benefit starts, Medicare does not pay for treatment or drugs intended to cure the terminal illness and related conditions rather than control symptoms, for care from a hospice other than the one chosen unless that hospice arranged it, for room and board where the patient lives, including a private home, assisted living, or a nursing home, or for outpatient, inpatient, or ambulance care related to the terminal illness that the hospice did not arrange.
Cost sharing is capped by regulation. 42 CFR 418.400 allows coinsurance of about 5 percent of the hospice's cost for each palliative outpatient prescription, not to exceed $5 per prescription, and 5 percent of the payment for each inpatient respite day, with respite coinsurance in a coinsurance period capped at that year's inpatient hospital deductible.
Revocation, discharge, and changing hospices
Under 42 CFR 418.28 the patient or representative may revoke the election at any time by filing a signed statement with the hospice, and the revocation cannot be backdated. The waived Medicare benefits resume, and the patient may elect hospice again later for any election period still available. The cost of revoking is that the remaining days in the current period are treated as used, under 42 U.S.C. 1395d(d)(2)(B).
Discharge is the hospice's action, not the patient's. 42 CFR 418.26 permits it only when the patient moves out of the service area or transfers, when the hospice determines the patient is no longer terminally ill, or for cause under a written policy that requires the hospice to warn the patient, try to resolve the problem, confirm the discharge is not because the patient needs services, and document all of it. A written discharge order from the hospice medical director comes first.
Changing hospices is not revocation. 42 CFR 418.30 treats a transfer as a change of designated provider, which does not consume an election period.
The role of the attending physician
The attending physician is defined at 42 U.S.C. 1395x(dd)(3)(B) as the physician, nurse practitioner, or physician assistant the patient identifies as having the most significant role in their care. The patient names that person on the election statement, and 42 CFR 418.24(b)(1) requires an acknowledgment that the choice was their own.
This is why a longtime primary care doctor does not disappear at admission. Under the carve out at 42 CFR 418.24(g)(2)(iii), the attending physician's services stay payable outside the hospice rate as long as that clinician is not employed or compensated by the hospice. To change attending physicians, 42 CFR 418.24(i) requires a signed statement naming the new one, effective no earlier than the date signed.
How families actually navigate it
The regulations describe a clean sequence. Families experience something messier, usually compressed into a few days. Read the election statement before signing, because it names the hospice and the attending physician and fixes the effective date. Ask for the addendum if any drug or service the patient depends on might be classified as unrelated. Keep a copy of the plan of care, which 42 CFR 418.200 requires to be established before care is provided. And know that revocation is always available and never permanent.
The coordination burden on families is the same one that appears across serious illness care, which is why roles like patient navigation exist and why caregiver support groups matter to the people doing the daily work. Transportation, housing, and food insecurity affect end of life care as much as any other kind, and are the domains covered by standard social needs screening tools.
Primary sources
- 42 U.S.C. 1395x(dd), section 1861(dd) of the Social Security Act: hospice care, terminally ill, and attending physician defined
- 42 CFR Part 418, the hospice regulations: 418.20 eligibility, 418.21 election periods, 418.22 certification, 418.24 election, 418.26 discharge, 418.28 revocation, 418.202 covered services, 418.204 special coverage, 418.302 payment levels
- 42 U.S.C. 1395d(a)(4) and (d): statutory benefit periods, election, and waiver
- CMS Medicare Benefit Policy Manual, Chapter 9, coverage of hospice services under hospital insurance
- Medicare.gov, Hospice care coverage, the official beneficiary explanation of exclusions
How to cite this page: FRANSiS, "The Medicare Hospice Benefit, Explained," fransis.ai, last reviewed August 4, 2026, https://www.fransis.ai/articles/medicare-hospice-benefit-explained.
This article is general information, not medical or legal advice. It describes federal rules and does not recommend any course of treatment. Coverage depends on individual circumstances and the rules change over time, so confirm your situation with the care team, the hospice, or Medicare directly.
Frequently Asked Questions
What is the Medicare hospice benefit?
It is a Medicare Part A benefit that pays a hospice a daily rate to provide palliative care to a person certified as terminally ill. The covered services at 42 CFR 418.202 include nursing, medical social services, physician services, counseling, aide and homemaker services, drugs for symptom control, medical equipment, and short term inpatient care, all under a written plan of care.
Who qualifies for hospice under Medicare?
Under 42 CFR 418.20 a person must be entitled to Medicare Part A and certified as terminally ill. Terminally ill is defined at 42 U.S.C. 1395x(dd)(3)(A) as a medical prognosis of a life expectancy of six months or less. For the first benefit period both the attending physician and the hospice medical director certify that prognosis in writing.
Does hospice end after six months?
No. Six months is a prognosis standard, not a time limit. 42 CFR 418.21 provides two 90 day periods followed by an unlimited number of 60 day periods, and 42 CFR 418.24(f) keeps a single election running through all of them. Care continues as long as a physician can recertify the prognosis at the start of each period.
What are the four levels of hospice care?
42 CFR 418.302(b) defines routine home care, continuous home care, inpatient respite care, and general inpatient care. Routine home care is the default. Continuous home care requires a period of crisis and at least eight hours of predominantly nursing care in a day. Respite is short term relief for caregivers, limited to five consecutive days. General inpatient care covers symptoms that cannot be managed elsewhere.
What does Medicare hospice not cover?
Medicare does not pay for treatment or drugs intended to cure the terminal illness, for care from a hospice other than the one elected unless that hospice arranged it, or for room and board where the patient lives, including a nursing home. Care related to the terminal illness that the hospice did not arrange may also be uncovered, so families should call the hospice first.
Can you leave hospice and go back to regular Medicare?
Yes. Under 42 CFR 418.28 a patient or representative may revoke the election at any time by filing a signed statement with the hospice. The revocation takes effect no earlier than the date it is made, the waived Medicare benefits resume, and the patient may elect hospice again later for any remaining election period.
Can you keep your own doctor on hospice?
Yes. The patient names an attending physician on the election statement under 42 CFR 418.24(b)(1), and that person may be a physician, nurse practitioner, or physician assistant. Under 42 CFR 418.24(g)(2)(iii) the attending physician's services stay payable outside the hospice daily rate as long as that clinician is not employed or compensated by the hospice.
What is the hospice election statement addendum?
It is a written list, titled "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" under 42 CFR 418.24(c), of the conditions, items, services, and drugs the hospice has determined are unrelated to the terminal illness and will not cover. 42 CFR 418.24(d) requires the hospice to provide it within five days if requested in the first five days of the election, or within three days later.
About this guide
Written for patients, families, and clinicians who need the federal rules stated plainly with citations they can check. Every provision described here was read against the current text of 42 CFR Part 418 and the United States Code. Last reviewed August 4, 2026. Not medical or legal advice.
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