Four Levels of Hospice Care Defined by Medicare

The four levels of hospice care, according to Medicare, are routine home care, continuous home care, general inpatient care, and respite care. A person qualified for hospice may experience one level of care or move between various levels depending on their specific needs. Every Medicare-certified hospice provider must offer all four levels of care.

If you have Medicare Part A and Part B, you don’t pay anything for hospice other than a 5% coinsurance fee for respite care. You would also need to pay a share of the costs for any services unrelated to your terminal diagnosis.

This article describes the services provided at each level of hospice care and when you would need them. It also explains which services may not be covered by Medicare and how to select the best hospice provider based on your needs and expectations.

Routine Home Care

Routine home care is a range of services you receive when you are not in a medical crisis. “Home” is defined by Medicare as your own home, a skilled nursing facility, or an assisted living facility such as a nursing home.

You would need routine home care if you are generally stable and your symptoms (such as pain, nausea, or vomiting) are adequately controlled.

Routine home care services can include:

• Physician services
• Nursing and medical services
• Durable medical equipment, like wheelchairs and oxygen machines
• Medical supplies, like bandages or catheters
• Drugs for pain and symptom management
• Hospice aide and homemaker services
• Physical therapy
• Occupational therapy
• Social worker services
  
• Dietary counseling and support
• Spiritual and grief counseling for you and your family
• Speech-language pathology therapy, particularly for issues like swallowing difficulties

According to research published in the Journal of the American Geriatric Society. routine home care is by far the most common level of hospice care among Medicare recipients.

Continuous Home Care

Continuous home care is for times when you need a higher level of nursing care, and your symptoms are not being adequately controlled. As with routine home care, continuous home care is delivered either in your home, a skilled nursing facility, or an assisted living facility.

Continuous home care is defined as needing a registered nurse (RN), licensed practical nurse (LPN), or licensed vocational nurse (LVN) for at least eight hours in a 24-hour period. You may receive care from other hospice team members, but at least 50% of the care must be delivered by an RN, LPN, or LVN.

The purpose of continuous home care is to achieve palliation (relief of acute symptoms) until your condition is stable.

Qualifying Symptoms

You may need continuous home care if you have:

• Uncontrolled pain
• Unrelenting nausea and vomiting
• Acute respiratory distress
• Agitation or “terminal restlessness”
• Seizures
• Caregivers who are unable to provide care

Continuous home care may be provided only during a period of crisis. Once your condition is stabilized, you will be returned to routine home care.

If your condition cannot be managed at your home or in an assisted living facility, you may need to be stepped up to general inpatient care.

General Inpatient Care

General inpatient (GIP) care is needed when pain and symptoms cannot be controlled in your home or an assisted living facility.

In such cases, you would need to be moved to a Medicare-certified hospice inpatient facility or a Medicare-certified hospital. If such facilities are not available, a Medicare-certified skilled nursing facility can be used.

The facility would be staffed with a 24-hour registered nurse (RN) with private areas to receive visitors at any time of the day. The treatment plan and decision to admit would be directed by your hospice team, typically the hospice medical director and/or designated physician.

The intention of GIP care is to achieve palliation until your symptoms are controlled and you are no longer in crisis.

Respite Care

Respite care is provided when your family or caregiver needs time away from the intensity of caregiving. Respite care is provided at a local Medicare-approved facility, such as a hospital, hospice inpatient facility, or nursing home.

Medicare limits respite care to five consecutive days and charges a daily 5% coinsurance fee. You can use respite care more than once, but only on an occasional basis. If you stay beyond five days, you may be liable for room and board charges.

Exclusions of Medicare Coverage for Hospice Care

When you qualify for hospice care under Medicare, all direct costs of care related to your terminal diagnosis are covered.

These items are not covered:

• Room and board: Medicare doesn’t cover room and board if you live at home or in an assisted living or skilled nursing facility. If your hospice team authorizes short-term GIP care or respite care, Medicare will cover those costs during the stay.
• Care from unapproved providers: All care you receive for your terminal diagnosis must be authorized or arranged by your hospice team, including emergency rooms and ambulances. However, you can still use your regular physician if you designate them as your attending hospice physician.
• Curative treatments: Hospice care is intended for those who decide to stop life-extending treatments. If you opt to pursue curative treatment, Medicare would cover some of the major costs of palliative care, but hospice benefits would cease.
  

Does Private Insurance Cover Hospice?

Most private health insurance plans do cover hospice care because it is generally less costly than treatment in a hospital. If hospice benefits are included, most direct costs will be covered, but check for any exclusions or limitations to avoid unexpected out-of-pocket expenses.

How to Choose a Hospice Provider

It is important to understand what Medicare covers and does not cover when choosing a hospice provider.

While the direct costs of your terminal diagnosis are fully covered by Medicare, room and board are not. This is where costs can vary considerably if you choose to (or need to) reside in a facility other than your home. Some facilities may exceed what you are able to afford.

While all hospice providers offer the same basic services per Medicare regulations, some only meet the minimal standard while others exceed them. And, although the providers are required by law to offer all four levels of care, the simple truth is that some are small and mainly equipped to deal with routine home care.

It is important, therefore, to ask the right questions when selecting a hospice provider, such as:

• How long have you been in business?
• What services do you provide?
• What support services can you provide me and my family?
• Will I have the same hospice nurse?
• Who is responsible for approving treatments, and how available are they to me?
• What other members of the hospice team might I see, and how often will I see them?
• How many people are assigned to each hospice nurse?
• Where would I go if I need inpatient care?
• Where would my family go if they need respite care?
  
• Can I speak with other caregivers to learn about their experience with your facility?
  

Summary

Medicare has four levels of hospice care: routine home care, continuous home care, general inpatient care, and respite care. You may need one or all levels of care depending on your unique needs and wishes.

The medical and support services associated with your terminal diagnosis are fully covered by Medicare Part A (with the exception of respite care, for which you are responsible for 5% of the daily fee).

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

1. Medicare.gov. Hospice levels of care.
2. Medicare.gov. Hospice care.
3. Centers for Medicare and Medicaid Services. Hospice.
4. Centers for Medicare and Medicaid Services. Medicare benefit policy manual. Chapter 9: Coverage of hospice services under hospital insurance.
5. Medicare.gov. More information about health care providers.
6. Unroe KT, Bernard B, Stump TE, Tu W, Callahan CM. Variation in hospice services by location of care: nursing home vs. assisted living facility vs. home. J Am Geriatr Soc. 2017;65(7):1490–1496. doi:10.1111/jgs.14826
7. National Hospice and Palliative Care Organization. Continuous home care in the Medicare hospice benefit.
8. National Hospice and Palliative Care Organization. Hospice general inpatient (GIP) level of care frequently asked questions.
9. Hospice Foundation of America. Paying for hospice care.
10. Centers for Medicare and Medicaid Services. Suggested questions to ask when choosing a hospice.

By Angela Morrow, RN
Angela Morrow, RN, BSN, CHPN, is a certified hospice and palliative care nurse.

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