11.2 Hospice and Palliative Benefits under Medicare, Medicaid, and Private Insurance

Why benefit rules show up on CHPN items

CHPN questions rarely ask you to quote a billing code. They ask whether the next nursing action matches the benefit the patient actually elected. Sending a Medicare hospice patient back to the oncologist for more disease-directed therapy of the terminal illness, promising that Medicare will pay a skilled nursing facility's monthly rent as general inpatient care (GIP), or telling a family that palliative care “is the same election as hospice” are classic misses.

Medicare Hospice Benefit (Part A)

The Medicare Hospice Benefit is a Part A benefit. Eligibility requires that the patient (or representative) is entitled to Part A and that a physician certifies terminal illness: a life expectancy of 6 months or less if the disease runs its normal course. The 6-month figure is a prognosis at certification, not a stopwatch. Patients who live longer remain eligible if the hospice physician recertifies that the prognosis still holds.

Election is the legal on-switch. The patient or representative signs a hospice election statement choosing hospice for the terminal illness and related conditions. That election waives Medicare payment for treatment intended to cure the terminal illness and related conditions, other than the hospice benefit itself and certain attending-physician services. Conditions unrelated to the terminal illness remain on Original Medicare (or the Medicare Advantage plan for unrelated care). Medicare.gov instructs hospices to give, on request, an addendum listing items, services, and drugs the hospice has determined are unrelated—typically within several days of the request—so families are not surprised by denials.

Once elected, related nursing visits, medical social work, counseling, aides, volunteers, durable medical equipment, supplies, and drugs for palliation of the terminal illness and related conditions are covered inside the hospice per diem. The hospice is responsible for arranging what the plan of care requires. Telling a family to “just send someone to the pharmacy and run it through Part D” for a related opioid is the wrong CHPN answer; the hospice must provide related palliative drugs.

If the patient is in a Medicare Advantage plan, Original Medicare is still billed for hospice care after election. The Advantage plan can continue covering services that are not part of the terminal illness or related conditions.

Four levels of care and benefit periods

Medicare pays hospice through four levels of care. Chapter 2 covers how each level is staffed and documented. This chapter places them in the benefit:

• Routine home care — the usual per diem in the home, assisted living, or nursing facility
• Continuous home care — short-term crisis care in the home, predominantly nursing, when symptoms cannot otherwise be managed
• Inpatient respite care — short-term inpatient stay to relieve the caregiver
• General inpatient care — short-term inpatient care for pain or other symptoms that cannot be managed in other settings

Benefit periods run two 90-day periods, then unlimited 60-day periods, always in that 90-90-60 order. Recertification of terminal illness is required at the start of each period. A face-to-face encounter by a hospice physician or hospice nurse practitioner is required before the third benefit period and before each later recertification (no more than 30 days before the recertification under the federal rule). The encounter supports the medical director's recertification; it is not a new “election.”

The patient may revoke hospice at any time. Remaining days in that benefit period are lost. A later re-election starts the next period; the two 90-day periods are not recycled. The patient may change hospice providers once per benefit period.

Coinsurance the exam still expects

Medicare pays the hospice for covered hospice care; there is no hospice deductible. CMS still allows limited coinsurance. Current Medicare consumer materials (including Medicare & You 2026 and Medicare.gov hospice coverage) and the Medicare Benefit Policy Manual describe:

• A copayment of up to $5 per prescription for outpatient drugs for pain and symptom management (the coinsurance approximates 5% of the hospice's drug cost, capped at $5 per prescription, and does not apply to drugs given during GIP or respite)
• 5% of the Medicare-approved amount for inpatient respite care, with the patient's respite coinsurance during a coinsurance period not exceeding the inpatient hospital deductible for the relevant year

Do not invent a 2026 visit copay or a new drug dollar amount beyond that longstanding $5 cap. Many hospices choose not to collect these amounts, but the CHPN still needs the CMS rule, not a local billing habit.

Palliative care is not a hospice election

Palliative care addresses quality of life in serious illness at any stage. It can occur with disease-directed treatment—chemotherapy, dialysis, left-ventricular assist devices, disease-modifying immunotherapy—when that treatment still matches goals. Medicare does not require a hospice-style election to receive palliative consultation. Physician and advanced-practice palliative visits are typically billed under ordinary Part B (or hospital) rules, not the hospice per diem. There is no 6-month certification requirement and no mandatory waiver of curative treatment.

CHPN trap: a patient with newly diagnosed metastatic cancer who wants both a palliative consult and oncology treatment does not have to elect hospice first. Conversely, a patient who has elected Medicare hospice generally cannot have the hospice and Medicare both pay for chemotherapy aimed at the terminal cancer unless the treatment is unrelated or a rare, documented exception applies.

Medicaid, private insurance, and the SNF room-and-board trap

Medicaid hospice is a state-administered benefit. Most states offer it, but covered services, concurrent-care rules, and room-and-board for nursing-facility residents vary. Under federal pediatric rules, children on Medicaid or CHIP may receive hospice and treatment of the terminal illness at the same time (concurrent care). Adult concurrent care is not the national Medicare default; some states and some managed-care contracts add it. Never assume a Medicaid hospice package matches Medicare.

Private insurance and some employer plans may cover palliative and hospice services with visit limits, prior authorization, or concurrent care that Medicare hospice does not offer. Read the payer, then teach the family what this plan will actually fund. Do not quote Medicare rules as if they bind a commercial plan.

Room-and-board in a skilled nursing facility is not automatically covered as GIP. If a hospice patient lives in a nursing facility on routine home care, Medicare pays the hospice the routine per diem; it does not pick up the facility's monthly room-and-board as if the patient were on GIP. Room-and-board may be paid by the patient, long-term care insurance, or Medicaid for dual-eligible residents—state rules apply. GIP is a short-term level of care for unmanaged pain or symptoms, usually in a contracted hospital or hospice inpatient bed. Moving a stable long-stay nursing-home patient to GIP solely to capture room-and-board is both a compliance problem and a wrong CHPN answer. Respite is likewise time-limited caregiver relief, not a backdoor nursing-home stay.

Exam scenario. A daughter asks the CHPN to “put Dad on GIP at the nursing home so Medicare will pay the rent” because he is tired but his pain is controlled on oral opioids. The correct teaching is that GIP requires a symptom crisis that cannot be managed at the current level, that routine hospice in a SNF does not include room-and-board, and that the team should look at Medicaid, private pay, or a true change in condition—not a fabricated GIP stay.