Hospice care in Pennsylvania is available to any resident whose physician certifies a life expectancy of six months or less and who agrees to shift from curative treatment to comfort-focused care. Medicare Part A pays for nearly all of it, leaving patients with only a small drug copayment and a five-percent coinsurance on respite stays. Pennsylvania Medical Assistance offers a parallel benefit for Medicaid-eligible residents and, importantly, covers nursing-facility room and board that Medicare will not.
Who Qualifies
The core requirement is a physician’s clinical judgment that the terminal illness will likely result in death within six months if the disease follows its expected course. It is a professional assessment, not a guarantee. Patients who live beyond six months are not pushed out of hospice; they stay enrolled as long as a physician recertifies that the terminal condition persists.
For the first benefit period, two physicians sign the certification: the hospice’s medical director (or a physician on the hospice team) and the patient’s own attending physician, if the patient has one. Every benefit period after that requires only the hospice physician or medical director to recertify.1eCFR. 42 CFR 418.22 – Certification of Terminal Illness
Pennsylvania Medical Assistance uses the same terminal-illness standard. To qualify under the state Medicaid program, the person must be categorically or medically needy, be certified as terminally ill by a physician, and not be a hospital inpatient at the time of election.2Legal Information Institute. 55 Pa Code 1130.22 – Duration of Coverage
Electing Hospice, Benefit Periods, and Revocation
Choosing hospice is a formal step. The patient (or a representative) signs an election statement identifying the hospice agency and attending physician, acknowledging that the care is palliative rather than curative, and confirming which Medicare-covered services are waived — essentially, curative treatments for the terminal condition. The statement includes cost-sharing information and contact details for the regional Quality Improvement Organization in case of a dispute.3eCFR. 42 CFR 418.24 – Election of Hospice Care
Medicare structures the coverage as benefit periods that run consecutively: an initial 90 days, a second 90 days, then an unlimited series of 60-day periods. There is no lifetime cap.4eCFR. 42 CFR 418.21 – Eligibility, Election and Duration of Benefits Beginning with the third benefit period, a hospice physician or nurse practitioner must conduct a face-to-face visit before recertification to gather clinical evidence that the prognosis still holds.1eCFR. 42 CFR 418.22 – Certification of Terminal Illness Pennsylvania Medicaid mirrors this approach and imposes no day limit on hospice coverage for recipients who remain certified.2Legal Information Institute. 55 Pa Code 1130.22 – Duration of Coverage
A patient can walk away from hospice at any time. Revocation is unconditional. No reason is required, and the request cannot be refused. Once revoked, the patient returns to standard Medicare and can resume curative treatment. Unused days in the current benefit period are forfeited, but the patient may re-elect hospice in any future benefit period if the illness progresses again.5eCFR. 42 CFR 418.28 – Revoking the Election of Hospice Care
What Hospice Covers
Hospice is delivered by an interdisciplinary team: physician, registered nurses, social workers, spiritual counselors, hospice aides, and trained volunteers. The care plan addresses the patient’s physical symptoms, emotional wellbeing, and spiritual concerns, and extends to family members who often need support of their own. Covered services include medications for pain and symptom management related to the terminal illness, durable medical equipment such as hospital beds and oxygen, and medical supplies. The hospice arranges all care connected to the terminal diagnosis; outside services the hospice team did not set up are generally not covered under the benefit.6Medicare.gov. Hospice Care
Every Medicare-certified hospice must offer four levels of care, matching intensity to the patient’s current condition. A patient can shift between them as needs change.
- Routine home care is the most common level, with hospice staff making intermittent visits to the patient’s home, personal care home, or nursing facility while family or facility staff provide day-to-day help between visits.
- Continuous home care is for a clinical crisis, typically uncontrolled pain or acute symptom escalation, and requires at least eight hours of predominantly nursing care within a 24-hour period to keep the patient at home.
- General inpatient care is a short-term admission to a hospital, hospice inpatient unit, or skilled nursing facility for symptom management that cannot be handled at home.
- Inpatient respite care is a facility stay of up to five consecutive days so the primary caregiver can rest; it can be used more than once on an occasional basis.
Bereavement support for family members is a required hospice service and must be available for up to one year after the patient’s death, though Medicare does not reimburse it separately.7eCFR. 42 CFR Part 418 – Hospice Care
The Room-and-Board Gap
Medicare’s hospice benefit is broad, but it will not pay for room and board at a nursing home or assisted living facility. If the patient lives in one of those settings, the family remains responsible for the facility’s daily rate unless the patient qualifies for Medicaid.6Medicare.gov. Hospice Care The exception is when the hospice team decides the patient needs short-term general inpatient care or respite care and arranges the admission itself; Medicare covers those stays because the purpose is symptom management or caregiver relief, not long-term housing.
Treatment for conditions unrelated to the terminal diagnosis stays with Original Medicare under the standard rules, meaning the patient pays the usual deductibles and coinsurance for that unrelated care.8Medicare.gov. Medicare Hospice Benefits
What It Costs
Most hospice patients in Pennsylvania pay little or nothing out of pocket. Medicare Part A charges a copayment of up to $5 per prescription for outpatient medications used for pain and symptom management, and five percent of the Medicare-approved daily amount for inpatient respite care. Routine home care, continuous home care, and general inpatient care carry no charge.9Centers for Medicare & Medicaid Services. Hospice
Pennsylvania Medical Assistance covers the same hospice services as Medicare for eligible residents, with no day limit as long as the patient is recertified.2Legal Information Institute. 55 Pa Code 1130.22 – Duration of Coverage The patient must meet the state’s categorical or medical-need requirements and waive certain Medicaid-covered services that duplicate hospice care.10Pennsylvania Code. 55 Pa Code 1130.21 – Recipient Eligibility Requirements The major practical advantage of Medicaid over Medicare alone is nursing-facility room and board. For a Medicaid-eligible patient living in a nursing home, the state’s Medicaid program pays the hospice at 95 percent of the skilled nursing facility rate, and the hospice passes that money through to the facility.11Medicaid.gov. Hospice Payments
Most commercial health plans include a hospice benefit comparable to Medicare’s, though copayments and covered services vary by policy. Review the plan documents or call the insurer before electing hospice. Patients without any coverage can self-pay, but the daily rates are substantial; many Pennsylvania hospices accept patients regardless of ability to pay, drawing on charitable funds or community donations.
Patient Rights
Revoking Hospice
A patient can revoke hospice and return to standard Medicare benefits at any time, for any reason. Revocation matters most when someone wants to pursue a new curative option, such as a clinical trial. It takes effect immediately, and re-election later is allowed.5eCFR. 42 CFR 418.28 – Revoking the Election of Hospice Care
Appealing a Discharge
If a hospice moves to discharge a patient, usually because the agency believes the terminal-illness standard is no longer met, the patient has the right to challenge the decision. The hospice must deliver a written Notice of Medicare Non-Coverage at least two days before services end, explaining the reason and providing contact information for the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). To appeal, the patient or representative contacts the BFCC-QIO by noon the day before the listed termination date. The QIO reviews the medical records, asks why coverage should continue, and issues a decision by the close of business the next day. If the patient cannot understand or sign for the notice, the hospice must reach a representative by phone or, failing that, send the notice by certified mail.12Medicare.gov. Fast Appeals
Advance Directives and Surrogate Decision-Makers
Pennsylvania law governs advance health care directives under Chapter 54 of Title 20 of the state’s consolidated statutes. A living will lets a person specify what medical treatment they do or do not want if they cannot communicate. A health care power of attorney names someone to make medical decisions on the patient’s behalf. Neither is required to enroll in hospice, but the intake team will typically ask whether they exist, and they are useful to have in place.
If a patient has no advance directive and cannot speak for themselves, Pennsylvania law sets a priority order of surrogate decision-makers: spouse, then adult child, parent, adult sibling, adult grandchild, and finally any adult with personal knowledge of the patient’s values and preferences. When multiple people share the same priority level, the provider may rely on a majority decision among those who have communicated a view.
Choosing a Hospice Provider
The Pennsylvania Department of Health licenses every hospice agency operating in the state and enforces minimum health and safety standards through periodic unannounced surveys. State licensure alone does not authorize Medicare payment. For that, the agency must also be certified by the Centers for Medicare and Medicaid Services, which contracts with the Department of Health to evaluate federal compliance through its own unannounced surveys.13Commonwealth of Pennsylvania. Hospice
Quality Metrics Worth Checking
Medicare’s Care Compare website lets families search hospice agencies by location and compare them on quality measures drawn from patient assessments, Medicare claims data, and the CAHPS Hospice Survey of patient and family experience.14Centers for Medicare & Medicaid Services. Current Measures
One useful measure is the Hospice Care Index, a composite score from 0 to 10 built from ten claims-based indicators. It reflects whether the agency provides adequate skilled nursing minutes per day, whether nurses visit on weekends, whether patients get visits near the time of death, and how often patients experience disruptive transitions like being discharged from hospice and then hospitalized. Higher scores indicate more consistent care. Agencies with fewer than 20 discharges over two years do not receive a score, so very small programs may not have comparable data.14Centers for Medicare & Medicaid Services. Current Measures
The Hospice Visits in Last Days of Life measure is also worth reviewing. It reports the share of a provider’s patients who received an in-person visit from a nurse or social worker on at least two of the final three days of life. Families often need the most support during those hours, and a low score is a warning sign.
Practical Questions to Ask
Confirm that the agency serves the patient’s geographic area and can provide timely visits, including 24-hour on-call nursing for symptom emergencies. Ask directly about average response time for after-hours calls; the answer varies significantly between agencies. Voluntary accreditation from bodies like The Joint Commission or the Community Health Accreditation Program signals compliance beyond the federal minimum, though many strong hospices operate without it.
Nonprofit hospices have consistently shown higher staffing ratios, more nursing and social worker visits per patient day, and better performance on the visits-near-death measure than for-profit counterparts. That is a pattern, not a rule about any individual agency. The Care Compare data lets families check the actual numbers rather than rely on an agency’s self-description.