Georgia Medicare End-of-Life Care Coverage

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By Brevy Care Team · Last verified May 13, 2026

End-of-life care is among the most consequential intersections of medicine, family decision-making, financial planning, and federal and state regulation that Medicare beneficiaries and their families navigate. The majority of Americans who die each year are Medicare beneficiaries by age or disability eligibility, and a disproportionate share of Medicare program spending occurs in the final year of life. The setting of death has shifted substantially over the past two decades, with hospital deaths declining and home deaths — often supported by hospice services — increasing. This shift reflects growing clinical and family recognition that aggressive treatment at end of life often does not meaningfully extend life and may diminish quality of remaining time. Hospice services are used by a significant share of Medicare beneficiaries in their final illness, and Georgia reflects national trends in this regard.

Medicare's framework for end-of-life care spans multiple statutory and regulatory provisions that interact with state law on advance directives. Section 1812(a)(4) of the Social Security Act establishes Medicare hospice as one of the four Part A benefit categories, with the substantive content defined at Section 1861(dd). The hospice benefit was added by the Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) as a 3-year demonstration and made permanent in 1986; it provides comprehensive end-of-life care for beneficiaries certified with terminal illness and a 6-month or shorter life expectancy if disease runs its natural course, requiring the beneficiary to elect hospice and forgo curative treatment for the terminal illness. Section 1861(s)(2)(GG) was added by the CMS-1631-FC final rule (Medicare Physician Fee Schedule for CY 2016, published October 30, 2015) and made Advance Care Planning a separately billable Medicare service effective January 1, 2016, representing the first time ACP conversations were paid as a distinct physician service. CPT 99497 covers the first 30 face-to-face minutes of advance care planning and CPT 99498 covers each additional 30 minutes. When performed as part of an Annual Wellness Visit, ACP carries $0 cost-sharing; when performed at other visits, standard 20 percent Part B coinsurance applies and is typically covered by Medigap. Section 1861(s)(2)(A) covers palliative care consultations, family conferences, and goals-of-care discussions as physician services with standard E&M billing.

The procedural backbone of end-of-life decision-making was established by the Patient Self-Determination Act of 1990, Section 4206 of the Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508), signed by President George H.W. Bush on November 5, 1990 with effective date December 1, 1991. The PSDA requires Medicare-participating providers (hospitals, skilled nursing facilities, home health agencies, hospices, and HMOs) to inform patients of their rights under state law to make advance directives, document in the medical record whether the patient has executed an advance directive, provide written information about facility policies, educate staff and community on advance directives, and not condition care or otherwise discriminate based on advance directive status. The PSDA is procedural rather than substantive: it does not create new substantive rights to advance directives (those are matters of state law) but requires Medicare providers to facilitate patient awareness and use of state-law advance directive mechanisms.

The substantive content of advance directives is governed by state law. In Georgia, the Advance Directive for Health Care Act, codified at O.C.G.A. §31-32 and substantially revised by House Bill 24 of the 2007 Georgia General Assembly effective July 1, 2007, consolidated Georgia's prior Living Will Act and Durable Power of Attorney for Health Care Act into a single statutory advance directive form. The Georgia advance directive has four parts that can be completed independently: Part 1 designates a health care agent (and successor agents); Part 2 expresses treatment preferences including specific preferences regarding mechanical ventilation, CPR, artificial nutrition and hydration; Part 3 nominates a guardian if one becomes necessary; Part 4 expresses anatomical gift preferences. Execution requires the declarant to be 18 or older and of sound mind, with two competent adult witnesses who are not health care providers directly involved in care, hospital or nursing home staff, persons financially responsible, or beneficiaries of the declarant's estate (with limited relative exceptions). Notarization is not required. Georgia POLST (Physician Orders for Life-Sustaining Treatment, contact 678-553-3500) is the medical-order companion to advance directives, translating patient preferences into actionable physician-signed medical orders that emergency medical services and hospital staff must honor in pre-hospital and emergency settings.

This guide is published by Brevy, the eldercare resource at brevy.com helping Georgia families understand and navigate the federal Medicare framework for end-of-life care, the Georgia Advance Directive for Health Care Act, POLST, palliative care, hospice election, family decision-making for incapacitated patients, withdrawal of life-sustaining treatment, and the practical coordination of these issues at major Georgia health systems including Emory Healthcare, Wellstar Health System, Piedmont Healthcare, Northside Hospital, Atrium Health Navicent, Memorial Health, Phoebe Putney Memorial Hospital, Augusta University Health, and Grady Health System. The information here is general educational content reflecting federal and Georgia state law and regulation as of May 2026. It is not personalized medical, legal, or financial advice. For specific advance directive completion, contact your physician or an attorney. For specific Medicare coverage questions, contact GeorgiaCares SHIP at 1-866-552-4464. For hospice referral, contact your physician or directly contact local hospice providers. For POLST forms, contact 678-553-3500 or the Georgia POLST Coalition. :::

::: callout Key Takeaways

1. Section 1812(a)(4) and Section 1861(dd) of the Social Security Act establish the Medicare hospice benefit as one of the four Part A benefit categories. Hospice was added by the Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) as a 3-year demonstration and made permanent in 1986. Hospice provides comprehensive end-of-life care for beneficiaries certified with terminal illness and 6-month or shorter life expectancy if disease runs its natural course. Beneficiary must elect hospice on Form CMS-1696 and forgo curative treatment for the terminal illness. Hospice provides nursing, medical/social services, physician services, counseling, short-term inpatient and respite care, home health aide, DME, medications related to the terminal illness, and therapy services with Medicare paying per-diem to the hospice provider.

2. Section 1861(s)(2)(GG) Advance Care Planning was added as a Medicare-covered service effective January 1, 2016 under the CMS-1631-FC final rule (Medicare Physician Fee Schedule for CY 2016, published October 30, 2015). ACP is billed as CPT 99497 for the first 30 face-to-face minutes (Medicare payment approximately $80-$85) and CPT 99498 for each additional 30 minutes (Medicare payment approximately $75). ACP may be performed by physicians or qualified health professionals (NPP, PA), must be face-to-face (with telehealth permitted in many circumstances), and may cover discussion of advance directives, treatment goals, preferences, palliative care, and hospice. When performed as part of an Annual Wellness Visit, ACP carries $0 cost-sharing; otherwise standard 20 percent Part B coinsurance applies and is typically covered by Medigap.

3. The Patient Self-Determination Act of 1990 (Section 4206 of the Omnibus Budget Reconciliation Act of 1990, Public Law 101-508, signed by President George H.W. Bush November 5, 1990, effective December 1, 1991) requires Medicare-participating providers to inform patients of their advance directive rights under state law, document whether the patient has an advance directive, provide written information about facility policies, educate staff and community, and not discriminate based on advance directive status. The PSDA is procedural; the substantive content of advance directives is state law.

4. The Georgia Advance Directive for Health Care Act, O.C.G.A. §31-32, was substantially revised in 2007 (HB 24 of the 2007 General Assembly, effective July 1, 2007) to consolidate prior Living Will and Durable Power of Attorney for Health Care into a single statutory form. The Georgia advance directive has four parts: Part 1 Health Care Agent designation, Part 2 Treatment Preferences, Part 3 Guardianship Designation, Part 4 Anatomical Gifts. Execution requires declarant 18 or older and of sound mind, two competent adult witnesses who are not health care providers in care, facility staff, financially responsible persons, or estate beneficiaries (with limited relative exceptions). Notarization is not required. Declarant can revoke at any time orally, in writing, or by destruction.

5. Georgia POLST (Physician Orders for Life-Sustaining Treatment, contact 678-553-3500) is the physician-signed medical order that translates patient preferences into actionable orders for emergency medical services and hospital staff. The Georgia POLST form has sections for CPR (Attempt or Do Not Attempt), Medical Interventions (Comfort Measures Only, Selective Treatment, Full Treatment), and Artificially Administered Nutrition. POLST is distinct from advance directives: the advance directive expresses preferences; POLST is a medical order based on those preferences. POLST is recognized by Georgia EMS and must be honored in pre-hospital settings.

6. Curative care, palliative care, and hospice care are distinct. Curative care aims to cure or control disease; Medicare covers all medically necessary curative care. Palliative care addresses relief from pain, symptoms, and stress of serious illness and can be provided alongside curative care at any disease stage; Medicare covers palliative care consultations under Section 1861(s)(2)(A) physician services with standard E&M coding and 20 percent Part B coinsurance. Hospice care is for terminally ill patients (6-month prognosis) who have elected to forgo curative treatment for the terminal illness; Medicare covers hospice under Section 1812(a)(4) per-diem with $0 patient cost beyond minimal drug copays.

7. Family conferences and goals-of-care discussions are reimbursable Medicare services. Inpatient setting: bundled into E&M codes (initial hospital visit 99221-99223, subsequent 99231-99233, prolonged services 99356-99357); ACP billed separately with CPT 99497/99498 when ACP-focused. Outpatient setting: office visit E&M codes plus optional ACP CPT 99497/99498. Hospital-based palliative care services in Georgia: Emory Palliative Care Center, Wellstar Palliative Care, Piedmont Palliative Care, Northside Hospital Palliative Care, Atrium Health Navicent Palliative Care, Memorial Health Palliative Care, and others.

8. Withdrawal of life-sustaining treatment at end of life is ethically and legally permitted under principles of autonomy, beneficence, nonmaleficence, and justice. Under O.C.G.A. §31-32, the designated health care agent has authority to decide. Without an advance directive, O.C.G.A. §31-9-2 establishes surrogate hierarchy (spouse, adult children, parents, adult siblings). Two-physician documentation may be required for withdrawal of nutrition/hydration in incompetent patients without advance directive. Georgia advance directives are inoperative during pregnancy under O.C.G.A. §31-32. Georgia does NOT permit physician aid in dying (medical aid in dying remains illegal in Georgia as of 2026). :::

The clinical case: Margaret 78 Atlanta metastatic pancreatic cancer at Emory

Consider Margaret, a 78-year-old retired Atlanta pharmacist who was diagnosed with metastatic pancreatic adenocarcinoma 8 months ago after presenting with painless jaundice and weight loss. She underwent ERCP with biliary stent placement at the time of diagnosis, then completed 4 cycles of first-line FOLFIRINOX chemotherapy at the Emory Winship Cancer Institute. Restaging imaging at month 6 demonstrated progressive disease with new liver metastases and increased size of peritoneal implants. Her oncologist discussed second-line gemcitabine plus nab-paclitaxel, which Margaret began. After 2 cycles, Margaret presented to the Emory University Hospital emergency department with recurrent jaundice from stent occlusion. ERCP with stent revision was performed. During the admission, Margaret's clinical course included worsening fatigue, decreased oral intake, and an obvious decline that her husband and two daughters all recognized.

On hospital day 2, the Emory inpatient palliative care consultation service was engaged at the request of Margaret's primary oncologist. The palliative care attending, a board-certified hospice and palliative medicine physician, met with Margaret and her family in her hospital room for 90 minutes. The conversation began with what Margaret understood about her illness ("I have pancreatic cancer that has spread, the chemo isn't working anymore"). It moved through what she hoped for ("more time with my grandchildren, comfort, to be home"), what she worried about ("being a burden, pain, machines"), and what she wanted to know about prognosis. The palliative care attending shared honestly that the expected prognosis was weeks to a few months, that further chemotherapy was unlikely to extend life meaningfully and would likely diminish quality, and that hospice could provide intensive comfort care at home with substantial Medicare coverage. Margaret listened carefully, asked questions, looked at her husband, and said: "I want to go home. I want to be comfortable. I don't want any more chemo."

The Emory palliative care team then guided Margaret through completion of a Georgia advance directive under O.C.G.A. §31-32. Margaret designated her husband John as primary health care agent, with her eldest daughter Sarah as successor agent. In the treatment preferences section, Margaret indicated that in the event of a terminal condition or permanently unconscious state, she did not want cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, or artificial hydration. She did want comfort measures including pain medications. The advance directive was witnessed by two adult staff members who were not directly involved in her care and were not financially responsible or estate beneficiaries.

The palliative care physician then completed a Georgia POLST form with Margaret: CPR "Do Not Attempt Resuscitation," Medical Interventions "Comfort Measures Only," Artificially Administered Nutrition "No artificial nutrition by tube." Margaret and the physician both signed. The POLST form was documented in the Emory electronic medical record and a physical copy was provided to Margaret to keep at home.

The next day, the discharge planning team coordinated hospice election with Hospice Atlanta. The Medicare hospice benefit was elected on Form CMS-1696. Margaret was discharged home with hospice services beginning the day of discharge: a registered nurse visit that afternoon for assessment and medication reconciliation, a hospital bed delivered the same day, a bedside commode, oxygen if needed, morphine and lorazepam for symptom management, and a chaplain contact. Over the next five weeks, hospice services included nursing visits twice weekly and then daily as Margaret declined, a home health aide three times weekly for bathing assistance, social work support for the family, and chaplain visits as Margaret requested. The hospice 24-hour phone line was used twice for symptom emergencies that the on-call nurse resolved without hospitalization.

Margaret died at home on a Sunday morning with John, Sarah, her younger daughter Caroline, and her two grandchildren present. The hospice nurse arrived within 80 minutes for pronouncement of death and bereavement support. The funeral home was contacted by the hospice. The family received bereavement support services from the hospice over the next 13 months as part of the Medicare hospice benefit.

The financial reality of Margaret's end-of-life care: the Emory inpatient palliative care consultation was billed under Section 1861(s)(2)(A) physician services with E&M code 99221 (initial inpatient consultation, $110 Medicare payment) plus CPT 99497 for the 30 minutes of advance care planning ($85 Medicare payment) plus CPT 99498 for the additional 60 minutes ($150 Medicare payment for two additional 30-minute increments). The hospital admission was paid under DRG 446 (Disorders of the Biliary Tract with CC). The hospice services were paid as Medicare hospice per-diem to Hospice Atlanta at approximately $220 per day Routine Home Care rate for 5 weeks (~$7,700 to Hospice Atlanta). Margaret's out-of-pocket costs across the entire episode: approximately $50 to $100 total because her Medigap Plan G policy covered Part A deductible and Part B coinsurance, and hospice services have no Medicare cost-sharing beyond minimal drug copays (which Hospice Atlanta absorbed). The total Medicare cost to the program for Margaret's last 6 weeks of life: approximately $20,000 to $25,000, far less than would have been incurred with continued chemotherapy and likely repeated hospitalizations.

The Medicare framework for end-of-life care

Medicare's framework for end-of-life care is built on the intersection of multiple statutory and regulatory provisions across decades of legislative action. Understanding the framework requires grasping each component.

Section 1812(a)(4) and Section 1861(dd): the Medicare hospice benefit

The Medicare hospice benefit is established under Section 1812(a)(4) of the Social Security Act, which lists hospice care as one of the four Part A benefit categories alongside inpatient hospital, skilled nursing facility, and home health. The substantive content is defined at Section 1861(dd), which specifies covered services, eligibility requirements, and the certification framework.

Hospice was added to Medicare by the Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248, signed by President Reagan September 3, 1982) initially as a 3-year demonstration. Following positive evaluation, hospice was made a permanent Medicare benefit in 1986. The legislative history reflects a deliberate policy choice to support an alternative care model focused on comfort rather than cure for terminally ill patients.

Key features of Medicare hospice:

Eligibility: The beneficiary's attending physician (if there is one) and the hospice medical director must certify that the beneficiary has a terminal illness with a life expectancy of 6 months or less if the disease runs its natural course. The certification must be specific and based on clinical assessment.

Election: The beneficiary or representative must elect hospice on Form CMS-1696, acknowledging that election means forgoing curative treatment for the terminal illness. Other Medicare benefits for unrelated conditions remain available; for example, a hospice patient with terminal cancer who breaks a hip from a fall can have the hip fracture treated under standard Medicare benefits.

Benefit periods: Hospice care is structured in two initial 90-day periods followed by unlimited 60-day periods. Recertification of terminal illness is required at the start of each new period.

Revocation and re-election: The beneficiary can revoke hospice election at any time and return to standard Medicare; subsequent re-election is permitted if eligibility criteria are met.

Covered services: Nursing services, medical and social services, physician services, counseling (spiritual, dietary, bereavement), short-term inpatient care for symptom management, short-term respite care for caregiver relief, home health aide and homemaker services, durable medical equipment, medical supplies, medications related to the terminal illness, physical/occupational/speech therapy.

Payment: Medicare pays the hospice provider per diem at one of four levels: Routine Home Care (most common), Continuous Home Care (during periods of crisis), Inpatient Respite Care (short respite for family), and General Inpatient Care (acute symptom management). The 2026 Routine Home Care rate is approximately $220 per day for the first 60 days and $175 per day after day 60, with substantial geographic and other adjustments. The aggregate cap per beneficiary per year (FY 2026) is approximately $34,000.

Section 1861(s)(2)(GG) and CMS-1631-FC: Advance Care Planning becomes Medicare-covered

Before January 1, 2016, advance care planning conversations between physicians and Medicare beneficiaries were not separately reimbursable. They were either bundled into other evaluation and management codes or simply represented unpaid physician time. This created a perverse incentive structure: physicians were paid for procedures and tests but not for the often-difficult conversations that should guide whether those procedures and tests are appropriate.

The CMS-1631-FC final rule (Medicare Physician Fee Schedule for CY 2016), published October 30, 2015 in the Federal Register, added advance care planning as a separately billable Medicare service effective January 1, 2016. The change was implemented under the authority of Section 1861(s)(2)(GG) of the Social Security Act.

CPT 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate. Medicare payment approximately $80-$85.

CPT 99498: Each additional 30 minutes. Medicare payment approximately $75.

Coverage requirements:

• Performed by a physician or qualified health professional (nurse practitioner, physician assistant, advanced practice clinician)
• Face-to-face requirement (with telehealth permitted in many circumstances post-COVID and ongoing)
• Patient must be present unless documented inability to participate (in which case discussion with family member or surrogate may be billed)
• May include discussion of advance directives, treatment goals and preferences, palliative care and hospice
• May be performed at any Medicare-covered visit including office, hospital, SNF, nursing facility, home
• May be performed as part of the Annual Wellness Visit with $0 cost-sharing
• May be performed at other visits with standard 20 percent Part B coinsurance

Documentation requirements: Time spent, persons present, topics discussed (advance directives, treatment goals, surrogate decision-makers), patient understanding, and any decisions made or forms completed.

Significance: The 2016 ACP coverage change was significant policy because it acknowledged that advance care planning is a clinical service worth dedicated payment. The change has been associated with increased rates of advance directive completion among Medicare beneficiaries, though substantial gaps in completion persist.

Section 1861(s)(2)(A): physician services including palliative care consultations

Section 1861(s)(2)(A) provides Medicare Part B coverage for "physicians' services" broadly, encompassing the full range of physician evaluation and management services. Palliative care consultations are physician services billed under standard E&M coding:

• 99221, 99222, 99223: Initial hospital inpatient or observation visit (low, moderate, high complexity)
• 99231, 99232, 99233: Subsequent hospital inpatient or observation visit (low, moderate, high complexity)
• 99202-99205: New outpatient office visit (low to high complexity)
• 99212-99215: Established outpatient office visit (low to high complexity)
• 99356, 99357: Prolonged inpatient services (each additional 30 minutes beyond E&M)
• 99417: Prolonged outpatient services
• 99497, 99498: Advance care planning (as discussed above)

Selection criteria under the 2021 E&M revisions are based on medical decision-making complexity or time. Palliative care consultations often qualify for higher complexity codes given the multiple chronic conditions, complex social and family dynamics, and high-stakes decision-making involved.

Cost-sharing: Standard Part B deductible ($257 in 2026) and 20% coinsurance. Medigap covers the 20% coinsurance for beneficiaries with Medigap.

The Patient Self-Determination Act of 1990

The Patient Self-Determination Act of 1990, codified as Section 4206 of the Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508), was signed by President George H.W. Bush on November 5, 1990 and took effect December 1, 1991. The PSDA was the federal government's response to growing public awareness of advance directives following the highly publicized cases of Nancy Cruzan and others, and the conclusion that Medicare beneficiaries and other patients should be informed of their state-law advance directive rights when they enter the health care system.

PSDA requirements apply to all Medicare-participating providers including hospitals, skilled nursing facilities, home health agencies, hospices, and HMOs:

1. Inform patients at the time of admission or enrollment of their rights under state law to make advance directives. Written information must be provided.

2. Document in the patient's medical record whether the patient has executed an advance directive.

3. Provide written information about the facility's policies regarding implementation of advance directives.

4. Educate staff on advance directives and their proper handling.

5. Educate the community served by the provider on advance directives through outreach activities.

6. Not condition care or otherwise discriminate against patients based on whether they have or have not executed an advance directive. A facility cannot require an advance directive as a condition of admission or refuse to treat based on advance directive status.

Procedural nature of PSDA: The PSDA does not create new substantive advance directive rights; those rights are matters of state law. The PSDA requires that Medicare providers facilitate patient awareness and use of state-law mechanisms. The substantive content of what an advance directive can say and how it operates is governed by each state's law.

Implementation in Georgia: Georgia Medicare-participating providers comply with PSDA by providing the Georgia advance directive form (or information about it) at admission, asking patients whether they have an advance directive, documenting the answer, and providing facility policy information.

The Georgia Advance Directive for Health Care Act: O.C.G.A. §31-32

The substantive law governing Georgia advance directives is the Advance Directive for Health Care Act, codified at O.C.G.A. §31-32. The current form of the Act dates from House Bill 24 of the 2007 Georgia General Assembly, signed by Governor Sonny Perdue and effective July 1, 2007. HB 24 was a substantial revision that consolidated Georgia's prior Living Will Act (which had expressed treatment preferences) and Durable Power of Attorney for Health Care Act (which had designated decision-makers) into a single statutory advance directive form with four parts.

Part 1: Health Care Agent designation

In Part 1, the declarant designates a health care agent (and optional successor agents) who will make health care decisions when the declarant lacks capacity. The agent has broad authority unless specifically limited by the declarant. The agent's authority becomes effective only when the declarant is determined to lack capacity by a physician.

Agent powers: The agent can make decisions regarding consent to or refusal of medical treatment, including life-sustaining treatment; access medical records; authorize disclosure of medical information; place the declarant in a health care facility; donate organs and tissues at death; and many other health-related matters.

Agent restrictions: The agent must act in accordance with the declarant's expressed preferences (if known) or in the declarant's best interest. The agent cannot consent to certain procedures restricted by law (involuntary commitment to psychiatric facility, abortion in some circumstances, sterilization without specific authorization, electroconvulsive therapy without specific authorization).

Who can serve as agent: Any competent adult (18+) other than the declarant's attending physician, an employee of the attending physician (unless related to declarant), an owner/operator/employee of a health care facility where declarant is or may be a patient (unless related). Spouses, adult children, parents, adult siblings, friends are all eligible.

Part 2: Treatment Preferences

In Part 2, the declarant expresses specific preferences regarding life-sustaining treatment. The Georgia form provides for preferences in three scenarios:

• Terminal condition: A condition that will cause death within a relatively short time without life-sustaining procedures
• Permanently unconscious state: A state of permanent unconsciousness
• Other condition: Conditions defined by the declarant

For each scenario, the declarant can indicate preferences regarding:

• Cardiopulmonary resuscitation (CPR)
• Mechanical ventilation
• Artificial nutrition (tube feeding)
• Artificial hydration (IV or tube fluids)
• Other specific treatments

Choices typically include: "I do not want," "I want a trial period," "I want," or "My agent decides."

Part 3: Guardianship Designation

In Part 3, the declarant can nominate a guardian to be considered by a probate court if guardianship becomes necessary. The nomination is not binding on the court but is influential. This is useful as a backup to the health care agent designation in case court-supervised guardianship is needed.

Part 4: Anatomical Gifts

In Part 4, the declarant can indicate organ and tissue donation preferences. This complements (but does not replace) Georgia driver's license organ donor designation.

Execution requirements

• Declarant: Must be 18 or older and of sound mind
• Two witnesses: Must be competent adults
• Witness restrictions: Witnesses cannot be the declarant's health care provider directly involved in care, hospital or nursing home staff, persons financially responsible for declarant's care, or beneficiaries of declarant's estate (with limited exceptions for relatives)
• Notarization: NOT required (unlike many states)

Revocation

The declarant can revoke the advance directive at any time:

• Orally
• In writing
• By destroying the form
• By executing a new advance directive

Revocation is effective when communicated to the health care agent or provider.

Out-of-state recognition

Georgia recognizes out-of-state advance directives validly executed under the laws of the state where executed.

Special provisions

Pregnancy exception: O.C.G.A. §31-32-3 provides that an advance directive is inoperative during pregnancy. This pregnancy clause has been the subject of constitutional debate (questions about whether such provisions violate constitutional autonomy rights) but remains in Georgia law.

Conflict between agent and treatment preferences: When the agent's instructions conflict with the declarant's expressed preferences in Part 2, the declarant's preferences generally control unless the agent has authority to override based on specific authorization.

Georgia POLST: Physician Orders for Life-Sustaining Treatment

POLST is fundamentally different from advance directives. The advance directive is a legal document expressing preferences. POLST is a physician-signed medical order based on those preferences that emergency responders and clinicians can immediately act on.

POLST originated in Oregon in 1991 (Oregon was the first state to develop the concept) and has spread nationwide under various names: POLST, MOLST (Medical Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), MOST (Medical Orders for Scope of Treatment). Georgia adopted POLST through the Georgia POLST Coalition founded in 2010.

Georgia POLST contact: 678-553-3500

The Georgia POLST form

The form is a single-page bright-pink document that travels with the patient. Sections include:

Section A: CPR (Cardiopulmonary Resuscitation):

• "Attempt Resuscitation/CPR"
• "Do Not Attempt Resuscitation/DNR/Allow Natural Death"

Section B: Medical Interventions: When the patient HAS a pulse and is breathing:

• "Full Treatment" - use intubation, advanced airway interventions, mechanical ventilation, defibrillation, ICU
• "Selective Treatment" - use medical treatment, IV fluids, IV antibiotics, cardiac monitoring; transfer to hospital only if comfort needs cannot be met
• "Comfort Measures Only" - relieve pain and suffering through medication, positioning, wound care, oxygen, suction; transfer only if comfort needs cannot be met at current location

Section C: Artificially Administered Nutrition: When the patient cannot take food by mouth:

• "No artificial nutrition by tube"
• "Defined trial period of artificial nutrition by tube"
• "Long-term artificial nutrition by tube"

Section D: Documentation of Discussion: Records who participated in the discussion (patient, family, agent, etc.).

Section E: Signatures: Physician/APRN signature; patient or representative signature.

When POLST is appropriate

POLST is appropriate for patients with serious illness or advanced frailty whose life expectancy may be limited and who want specific treatment limits documented as actionable medical orders. POLST is NOT appropriate for healthy patients (advance directive is more appropriate for that purpose).

EMS recognition

POLST is recognized by Georgia EMS and must be honored by EMS providers in pre-hospital settings. This is the operational value of POLST: an EMS responder arriving at a home where a patient is in cardiac arrest can see the POLST form and act accordingly (attempting resuscitation if the form says "Attempt Resuscitation" or providing comfort measures if it says "Do Not Attempt Resuscitation").

Storage and portability

POLST should be kept where it can be quickly accessed: at home prominently displayed (refrigerator or near bed), at any facility where the patient resides (nursing home, assisted living), and in the patient's medical record. The form travels with the patient between care settings.

The distinction between curative care, palliative care, and hospice care

A foundational confusion in end-of-life care is the relationship between these three approaches:

Curative care

Treatment focused on curing or controlling disease progression. Examples: chemotherapy, radiation, surgery, dialysis, mechanical ventilation, transplant. Medicare covers all medically necessary curative care under standard Part A and Part B benefits.

Palliative care

Specialized medical care focused on relief from pain, symptoms, and stress of serious illness. The goal is improving quality of life for patient and family. Key features:

• Can be provided alongside curative care: A cancer patient can receive chemotherapy AND palliative care simultaneously
• Any stage of illness: Not limited to end of life
• Any age: From pediatric to geriatric
• Provided by: Board-certified palliative medicine physicians, palliative care nurse practitioners, palliative care nurses, social workers, chaplains, pharmacists
• Settings: Hospital, outpatient clinic, home, nursing facility, telehealth

Medicare covers palliative care consultations as physician services under Section 1861(s)(2)(A) with standard E&M billing. Cost-sharing is the standard 20% Part B coinsurance (covered by Medigap).

Hospice care

Specialized care for terminally ill patients (6-month prognosis if disease runs its natural course) who have elected to forgo curative treatment for the terminal illness. Key features:

• Requires election: The beneficiary or representative must elect hospice and forgo curative treatment for the terminal illness
• Medicare hospice benefit: A discrete Medicare benefit under Section 1812(a)(4) with its own per-diem payment, services, and structure
• Other conditions remain covered: A hospice patient with terminal cancer can still have unrelated conditions (broken hip, appendicitis) treated under standard Medicare
• Settings: Home (most common), hospice facility, nursing facility, hospital
• Coverage: All-inclusive per-diem payment to hospice provider; near-zero patient cost-sharing

Common misconceptions

"Palliative care = giving up": FALSE. Palliative care addresses symptom relief regardless of curative status.

"Hospice = doing nothing": FALSE. Hospice provides intensive comfort-focused care.

"Hospice is only for cancer patients": FALSE. Heart failure, COPD, dementia, ESRD, ALS, liver disease, and many other conditions qualify.

"You have to be in the last weeks of life for hospice": FALSE. Hospice eligibility is 6-month prognosis if disease runs natural course; many patients live longer with hospice support.

"Hospice means you have to be at home": FALSE. Hospice can be provided in nursing facilities, hospice facilities, and hospitals.

Worked example two: Robert 82 Savannah end-stage heart failure with POLST at Memorial Health

Robert 82, retired insurance agent, has ischemic cardiomyopathy NYHA Class IV symptoms with ejection fraction 15 percent. Over the past year, he has had four hospitalizations at Memorial Health Savannah for acute decompensated heart failure, each requiring IV diuresis and stabilization. His cardiologist initiates palliative care consultation during the most recent admission.

The Memorial Health palliative care physician, a board-certified hospice and palliative medicine specialist, engages Robert and his wife Eleanor and son in a 90-minute family conference on hospital day 2. The conversation explores Robert's clear preference to remain at home, avoid further ICU admissions, and focus on quality of remaining time. Robert understands his prognosis (likely 6 to 12 months given his clinical trajectory).

The palliative care physician guides completion of a Georgia advance directive under O.C.G.A. §31-32. Robert designates Eleanor as primary health care agent and his son as successor. Treatment preferences: no CPR, no intubation, no ICU; comfort-focused care with home-based management. Witnesses are two adult Memorial Health staff who are not directly involved in care.

The palliative care physician then completes a Georgia POLST form: CPR "Do Not Attempt Resuscitation," Medical Interventions "Selective Treatment" (IV fluids and antibiotics permitted but no intubation), Artificial Nutrition "No artificial nutrition by tube." Both the physician and Robert sign. The POLST is documented in the Memorial Health EMR and a copy is provided to Robert.

Robert is discharged home with optimized oral diuretic regimen and outpatient palliative care follow-up at the Memorial Health Palliative Care Outpatient Clinic. Not yet hospice-eligible (prognosis estimated 9-12 months).

Six months later, Robert's condition deteriorates with progressive functional decline, declining oral intake, and worsening symptoms despite optimized medical management. Memorial Health palliative care physician and primary cardiologist jointly determine 6-month prognosis criteria are met. Hospice election with Hospice Savannah. Robert dies at home with Eleanor and his son present 4 months after hospice election.

Billing:

• Memorial Health inpatient consult: 99221 ($110) + CPT 99497 ($85) for ACP portion = $195 to physician group
• 6 months of outpatient palliative care visits: 99214 × 8 visits ($110 each = $880)
• Hospice per-diem to Hospice Savannah at ~$220/day × 122 days ≈ $26,840
• Robert's out-of-pocket cost: approximately $0 to $200 across the entire trajectory (Medigap Plan G covers Part B coinsurance; hospice has near-zero cost-sharing)

Worked example three: Linda 76 Macon advanced dementia at Atrium Health Navicent

Linda 76 has advanced Alzheimer's disease diagnosed 6 years ago. She is now in moderate-severe stage requiring 24-hour supervision. She lives at home with her daughter as primary caregiver. Linda has not previously completed an advance directive. Her daughter brings her to the Atrium Health Navicent geriatrics clinic for evaluation and care planning.

The geriatrician engages Linda in conversation. Linda has limited capacity for complex decisions but can express simple preferences. She indicates she does not want to be in a hospital and does not want machines.

The geriatrician convenes a family meeting with Linda, her daughter, her son, the geriatrics nurse practitioner, and the social worker. The conversation explores Linda's expressed wishes and her family's understanding of her values. Linda's daughter recalls Linda saying she wouldn't want to live "hooked up to tubes."

Because Linda has limited capacity for full advance directive completion, the daughter pursues durable power of attorney for health care via the O.C.G.A. §31-9 statutory surrogate process. Linda has capacity to designate her daughter as agent and signs the designation with two witnesses. A separate treatment preferences document is completed by the daughter (as agent) reflecting Linda's expressed wishes: no CPR, no mechanical ventilation, no artificial nutrition; comfort measures permitted.

POLST is not yet signed but planned for when Linda's condition reaches the threshold for actionable medical orders. Palliative care referral is made for ongoing symptom management. Hospice election is anticipated as dementia progresses.

Billing:

• Family meeting + ACP: CPT 99497 ($85)
• Geriatrics office visit: 99214 ($110)
• Total Linda's cost-sharing with Medigap: approximately $0

Worked example four: Charles 84 Augusta sudden CVA at AU Health without advance directive

Charles 84, retired electrician, has no prior advance directive. He develops sudden onset right hemiplegia and global aphasia while at home. His wife Mary calls EMS. Tift County EMS transports to Augusta University Health emergency department. CT brain shows large left middle cerebral artery infarct. Charles is outside the time window for tissue plasminogen activator. Stroke team admits to neuro ICU for monitoring.

Charles is incapacitated and cannot communicate. He has no advance directive. The surrogate decision-maker hierarchy under O.C.G.A. §31-9-2 applies: spouse Mary is the surrogate.

The AU Health stroke team and palliative care consultant convene a family meeting on hospital day 2 with Mary, her two daughters, and the clinical team. The conversation lasts 90 minutes. Topics include:

• Clinical status: dense left MCA infarct, residual right hemiplegia and aphasia, prognosis for meaningful recovery limited
• Charles's prior expressed wishes: Mary recalls Charles saying he wouldn't want to live as a "burden" or "hooked up to machines"; daughter recalls Charles saying he wouldn't want to live in a nursing home
• Treatment options: aggressive interventions (PEG tube for nutrition, tracheostomy if respiratory failure, ICU level care indefinitely) versus comfort-focused care (palliative care unit transfer, symptom management, no aggressive interventions)
• The family's burden of surrogate decision-making without prior expressed wishes

Mary as surrogate decides on comfort care after extensive discussion. The clinical team agrees this is consistent with Charles's expressed values. Two physicians document the surrogate decision in accordance with O.C.G.A. §31-9 procedures for incompetent patients without advance directive.

Charles is transferred from the neuro ICU to the AU Health palliative care unit. He dies 6 days later with Mary and his daughters present.

Key teaching points:

1. Without prior advance directive, family bears extraordinary burden of surrogate decision-making during crisis
2. Surrogate hierarchy in O.C.G.A. §31-9-2 governs absent advance directive: spouse, adult children, parents, adult siblings, etc.
3. Two-physician documentation is required for withdrawal of nutrition/hydration in incompetent patients without advance directive in some Georgia practice settings
4. This case illustrates the value of completing advance directives BEFORE crisis, when the patient can express preferences and family can absorb information calmly

Worked example five: Patricia 79 Columbus chronic lung disease at Piedmont Columbus

Patricia 79, retired retail manager, has severe COPD GOLD stage IV with three hospitalizations in the past year for exacerbations. FEV1 25 percent predicted. On home oxygen 24/7. Her pulmonologist refers her to the Piedmont Columbus Palliative Care Outpatient Clinic.

Over 6 months of outpatient palliative care visits, the palliative care physician addresses:

• Symptom management: Chronic dyspnea managed with low-dose oral morphine, anxiety managed with low-dose lorazepam, optimization of bronchodilators
• Advance care planning: Identification of treatment preferences, completion of Georgia advance directive with daughter as agent, POLST completion (CPR Not Attempted, Selective Treatment, no intubation)
• Family meetings: Two meetings over 6 months involving Patricia, her daughter, and her son to align on goals and prepare for likely future events
• Coordination with primary care and pulmonology: Sharing of palliative care plan with primary care physician and pulmonologist

After 6 months of palliative care, Patricia's condition deteriorates with progressive functional decline, worsening hypercapnia, and inability to leave home. Pulmonologist and palliative care physician jointly determine hospice eligibility (6-month prognosis criteria met). Hospice election with Hospice of Columbus. Patricia dies at home 4 months later with daughter and son present.

Billing across 6 months:

• Office visits: 99214 × 8 visits ($880 total)
• ACP discussions: CPT 99497 × 4 visits ($340 total)
• Hospice per-diem after election: ~$220/day × 122 days ≈ $26,840
• Patricia's cost-sharing with Medigap: approximately $0

Worked example six: Henry 88 rural Tifton home death with hospice support

Henry 88, retired farmer, has advanced congestive heart failure and progressive cognitive decline. He lives with his wife Dorothy 85 in a rural farmhouse outside Tifton. His primary care physician at Tift Regional Medical Center refers him for home hospice through Tift Regional Hospice.

Hospice services provided over the next 7 weeks:

• Registered nurse visits: Twice weekly initially, more frequent as Henry's condition declines
• Home health aide: Three times weekly for bathing and personal care
• Social worker visits: Monthly for family support and care planning
• Chaplain visits: Per family preference; weekly during last 2 weeks
• Medications: All medications related to terminal illness delivered to home including opioids for symptom management, anxiolytics, antiemetics, bowel regimen
• Durable medical equipment: Hospital bed, bedside commode, wheelchair delivered to home
• 24/7 phone line: Used twice during the 7 weeks for symptom emergencies that the on-call nurse resolved without hospitalization
• Continuous home care: Not needed but available if a symptom crisis had occurred

Dorothy is the primary caregiver, supported by their daughter who visits 3 times weekly from Albany. Dorothy participates in the hospice caregiver support group.

Henry dies at home on a Tuesday morning with Dorothy and their daughter present. The hospice nurse arrives within 90 minutes for pronouncement of death and bereavement support. The funeral home (Tifton Funeral Home) is contacted by the hospice. The family receives bereavement support services from Tift Regional Hospice over the next 13 months as part of the Medicare hospice benefit.

Billing:

• Hospice per-diem to Tift Regional Hospice at ~$220/day × 49 days = ~$10,780
• Henry's cost-sharing: $0 (Medicare hospice benefit + Medigap coverage)

This case illustrates that rural Georgia hospice care is accessible and effective. Hospice does not require an urban or academic setting; rural community hospices provide excellent end-of-life care.

Fourteen common mistakes in end-of-life care navigation

Mistake 1: Not completing an advance directive while cognitively able. Postponing leads to crisis decisions by family without guidance from the patient's prior expressed wishes.

Mistake 2: Confusing advance directive with POLST. They are different documents serving different functions: advance directive expresses preferences (legal document); POLST is a medical order based on those preferences (executable in emergency settings).

Mistake 3: Not designating a health care agent. Without an agent, the surrogate hierarchy under O.C.G.A. §31-9-2 applies, which may not match the patient's preferences.

Mistake 4: Not communicating preferences to family and physician. A written advance directive that no one knows about is less useful than verbal communication of preferences.

Mistake 5: Confusing palliative care with hospice. Palliative care can be received alongside curative treatment at any stage; hospice requires forgoing curative treatment for the terminal illness.

Mistake 6: Equating hospice with "giving up." Hospice is active, intensive, comfort-focused care, not absence of care.

Mistake 7: Waiting too long to consider hospice. Many patients enter hospice in the last 1-2 weeks of life when they could have benefited from months of hospice support.

Mistake 8: Not asking about ACP coverage at AWV. Annual Wellness Visit includes $0 cost-sharing for ACP. Ask the primary care physician to include ACP at the next AWV.

Mistake 9: Not exploring values and preferences during good health. Values discussions are easier and more reliable when the patient is well, not in crisis.

Mistake 10: Assuming pregnancy clauses don't apply. Georgia advance directives are inoperative during pregnancy under O.C.G.A. §31-32-3.

Mistake 11: Not understanding Georgia's two-witness requirement. Invalid execution invalidates the document. Witnesses cannot be health care providers in care, facility staff, financially responsible persons, or estate beneficiaries (with limited relative exceptions).

Mistake 12: Disregarding patient's preferences when patient regains capacity. A patient with capacity always trumps prior expressed preferences in advance directives.

Mistake 13: Not coordinating with primary care after advance directive completion. Give a copy to primary care, the hospital, the designated agent, and family. The document is useless if no one has access.

Mistake 14: Not considering POLST when serious illness develops. POLST is the actionable medical order that EMS and emergency staff will follow. Advance directives alone may not be operative quickly enough in emergency settings.

Medicare Advantage and end-of-life care

Medicare Advantage plans must cover hospice (which is a carve-out: hospice services are paid by Original Medicare even for MA enrollees), palliative care consultations, and advance care planning. Some MA plans offer expanded end-of-life supplemental benefits:

In-home support services for chronically ill enrollees: Under Section 1395w-22(a)(3), MA plans can offer non-medical supplemental benefits to chronically ill enrollees including caregiver support, meal delivery, transportation, home modifications. Some MA plans offer end-of-life-specific supplemental benefits.

Concurrent care pilots: Some MA plans have implemented pilots allowing concurrent curative treatment alongside hospice, addressing the traditional limitation that hospice election requires forgoing curative care for the terminal illness. Eligibility and coverage vary.

Care coordination: Many MA plans provide enhanced care coordination for end-of-life care, including dedicated case managers, palliative care care navigation, and family support.

Dual-eligible Medicare/Medicaid and end-of-life care

For Georgia residents who qualify for both Medicare and Medicaid (Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, Qualifying Individual, or full-benefit dual-eligibility), Georgia Medicaid (DCH 1-866-211-0950) provides important supplementary coverage:

Nursing facility room and board: When a hospice patient resides in a nursing facility, Medicare hospice covers the hospice services but does NOT cover nursing facility room and board. Medicaid covers nursing facility room and board for full-benefit dual-eligibles, making hospice in nursing facility settings feasible for low-income beneficiaries.

Custodial care: Medicaid covers custodial care that Medicare does not cover, addressing the gap when end-of-life care is needed but does not meet skilled care criteria.

Part B coinsurance: Medicaid covers Medicare Part B cost-sharing for dual-eligibles, including coinsurance on palliative care office visits.

Caregiver support: Some Georgia Medicaid waiver programs (CCSP, SOURCE) provide caregiver support services that complement Medicare end-of-life care.

Appeals and grievances in end-of-life care

Medicare beneficiaries who experience problems with end-of-life care coverage can pursue appeals:

Hospice coverage denials: If a hospice provider refuses to certify or recertify a beneficiary, the beneficiary can appeal the certification decision. The hospice provider's own appeals process is the first step; Medicare appeals levels follow if needed.

Palliative care or ACP coverage denials: Standard Medicare appeals process: redetermination by Palmetto GBA (1-877-567-9230), reconsideration by QIC, ALJ, Medicare Appeals Council, federal district court.

MA plan denials: Use the MA plan's appeals process; QIO Kepro (1-844-455-8708) for some QIC functions.

Quality concerns: Kepro QIO (1-844-455-8708) handles quality complaints regarding end-of-life care including premature discharge, inadequate symptom management, or other quality issues.

How Brevy helps Georgia families navigate end-of-life care

Brevy (brevy.com) is the eldercare resource helping Georgia families navigate the complex intersection of Medicare hospice, Medicare Advance Care Planning, palliative care, Georgia advance directives under O.C.G.A. §31-32, Georgia POLST, family decision-making, and the practical realities of end-of-life care at major Georgia health systems. End-of-life care touches on the most personal and consequential decisions families face, and the regulatory complexity (federal Medicare framework intersecting with Georgia state law) can obscure the underlying choices. Brevy's mission is to translate this complexity into actionable understanding so that Georgia families can make end-of-life decisions in advance, document them properly under Georgia law, communicate them effectively to clinicians and family, and access the Medicare-covered services (palliative care, hospice, ACP) that support a good death.

::: accordion Q1: What is the Medicare hospice benefit?

Established under Section 1812(a)(4) and Section 1861(dd) of the Social Security Act, the Medicare hospice benefit provides comprehensive end-of-life care for beneficiaries certified with terminal illness and 6-month or shorter life expectancy if disease runs its natural course. The beneficiary elects hospice and forgoes curative treatment for the terminal illness. Hospice covers nursing, medical/social services, physician services, counseling, short-term inpatient and respite care, home health aide, DME, medications related to terminal illness, and therapy services paid per-diem to the hospice provider.

Q2: What is Advance Care Planning under Medicare?

Effective January 1, 2016 under CMS-1631-FC, Medicare covers Advance Care Planning as a separately billable service under Section 1861(s)(2)(GG). ACP is billed as CPT 99497 for the first 30 face-to-face minutes (Medicare payment $80-85) and CPT 99498 for each additional 30 minutes ($75). When performed as part of an Annual Wellness Visit, ACP has $0 cost-sharing; otherwise standard 20% Part B coinsurance applies.

Q3: What is the Patient Self-Determination Act?

The Patient Self-Determination Act of 1990 (Public Law 101-508 Section 4206, signed by President George H.W. Bush November 5, 1990, effective December 1, 1991) requires Medicare-participating providers to inform patients of their advance directive rights, document whether the patient has an advance directive, provide written information about facility policies, educate staff and community, and not discriminate based on advance directive status. The PSDA is procedural; substantive advance directive law is state law.

Q4: What is the Georgia Advance Directive for Health Care Act?

The Georgia Advance Directive for Health Care Act, codified at O.C.G.A. §31-32 and revised in 2007 (HB 24, effective July 1, 2007), consolidated prior Georgia Living Will and Durable Power of Attorney for Health Care into a single statutory advance directive form. The form has four parts: Part 1 Health Care Agent designation, Part 2 Treatment Preferences, Part 3 Guardianship Designation, Part 4 Anatomical Gifts.

Q5: How do I complete a Georgia advance directive?

(1) Obtain the Georgia advance directive form from Georgia Department of Public Health, Georgia State Bar, Aging with Dignity Five Wishes, or your health care provider; (2) Complete the four parts as desired; (3) Sign in the presence of two competent adult witnesses who are not health care providers in your care, facility staff, financially responsible persons, or estate beneficiaries (with limited relative exceptions); (4) Distribute copies to your designated agent, primary care physician, hospital(s), and family; (5) Notarization is not required.

Q6: What is POLST and how does it differ from an advance directive?

POLST (Physician Orders for Life-Sustaining Treatment) is a physician-signed medical order that translates patient advance directive preferences into actionable orders for emergency settings. Advance directive expresses preferences (legal document). POLST is a medical order EMS and clinicians will follow. POLST is appropriate for patients with serious illness whose life expectancy may be limited.

Q7: How do I get a Georgia POLST form?

Contact the Georgia POLST Coalition at 678-553-3500. Forms are typically completed with a physician or APRN. The bright-pink single-page form is signed by the clinician and the patient (or representative) and should be kept where it is easily accessible (refrigerator, near bed, with patient at facilities).

Q8: What is the difference between curative, palliative, and hospice care?

Curative care aims to cure or control disease. Palliative care addresses symptom relief and quality of life and can be provided alongside curative care at any stage. Hospice care is for terminally ill patients (6-month prognosis) who have elected to forgo curative treatment for the terminal illness. Palliative care is covered under Section 1861(s)(2)(A) physician services with standard 20% coinsurance; hospice is covered under Section 1812(a)(4) with near-zero cost-sharing.

Q9: How do I find a palliative care physician in Georgia?

Most Georgia health systems have palliative care services: Emory Palliative Care Center, Wellstar Palliative Care, Piedmont Palliative Care, Northside Hospital Palliative Care, Atrium Health Navicent Palliative Care, Memorial Health Palliative Care, AU Health Palliative Care, Grady Palliative Care, Phoebe Putney Palliative Care. Many hospices also offer non-hospice palliative care services. Ask your primary care physician for referral.

Q10: When is hospice appropriate?

Hospice is appropriate when (1) a physician certifies terminal illness with 6-month or shorter life expectancy if disease runs natural course, (2) the patient or representative elects hospice, and (3) the patient is willing to forgo curative treatment for the terminal illness. Many qualifying conditions: cancer, advanced heart failure, advanced COPD, advanced dementia, ESRD off dialysis, ALS, liver disease, and others.

Q11: Can I revoke hospice and return to standard Medicare?

Yes. The beneficiary can revoke hospice election at any time and return to standard Medicare. Subsequent re-election of hospice is permitted if eligibility criteria are met. This flexibility is important for patients who may want to try a curative treatment after hospice election.

Q12: How does hospice payment work?

Medicare pays the hospice provider per-diem at four levels: Routine Home Care (~$220/day in 2026), Continuous Home Care (during symptom crisis), Inpatient Respite Care (short respite for family), and General Inpatient Care (acute symptom management requiring inpatient). The aggregate cap per beneficiary per year (FY 2026) is approximately $34,000.

Q13: Are there any out-of-pocket costs for hospice?

Near-zero. Medicare hospice has minimal cost-sharing: copays up to $5 per drug for outpatient prescription drugs related to the terminal illness, and 5% coinsurance for inpatient respite care. Medigap and Medicaid for dual-eligibles cover these small costs.

Q14: What does palliative care cost?

Palliative care office visits are billed as physician services under Section 1861(s)(2)(A) with standard E&M coding. Cost-sharing is the standard Part B deductible ($257 in 2026) and 20% coinsurance. Medigap covers the 20% coinsurance. Total typical out-of-pocket cost for palliative care without Medigap is approximately $25-50 per visit; with Medigap, approximately $0.

Q15: How does Medicare cover withdrawal of life-sustaining treatment?

Withdrawal of life-sustaining treatment (mechanical ventilation, vasopressors, dialysis, artificial nutrition, antibiotics) is permitted under ethical and legal frameworks. Medicare covers the clinical services involved: physician services, hospital services, palliative care, and any subsequent hospice services. The decisions themselves are matters of patient autonomy (or surrogate decision-making for incapacitated patients) governed by state law.

Q16: Who decides for an incapacitated patient without an advance directive?

Under O.C.G.A. §31-9-2, the surrogate hierarchy is: spouse, adult children, parents, adult siblings, etc. For some decisions (particularly withdrawal of nutrition/hydration), two physicians may be required to document specific criteria. This is why advance directive completion BEFORE crisis is so valuable.

Q17: Can my advance directive be honored in another state?

Generally yes. Georgia recognizes out-of-state advance directives validly executed under the laws of the state where executed. Most states have reciprocal provisions, though the specific operative terms may be interpreted differently in different states.

Q18: What happens to my advance directive during pregnancy?

Under O.C.G.A. §31-32-3, Georgia advance directives are inoperative during pregnancy. This pregnancy clause has been the subject of constitutional debate but remains in Georgia law.

Q19: Can I change or revoke my advance directive?

Yes. The declarant can revoke at any time orally, in writing, by destroying the form, or by executing a new advance directive. The revocation is effective when communicated to the health care agent or provider.

Q20: Does Georgia permit physician aid in dying?

No. Georgia does NOT permit physician aid in dying (medical aid in dying, physician-assisted suicide). As of 2026, 10 jurisdictions permit it (Oregon, Washington, Vermont, California, Colorado, DC, Hawaii, Maine, New Jersey, New Mexico, plus Montana via court ruling).

Q21: How does Medicare Advantage handle hospice?

Hospice is a carve-out to Original Medicare for MA enrollees: even when enrolled in an MA plan, hospice services are paid by Original Medicare. MA plans cover non-hospice services (the patient's other medical care for unrelated conditions) and may offer supplemental end-of-life benefits.

Q22: What if my family disagrees about my end-of-life care?

If you have completed an advance directive designating a health care agent, that agent has decision-making authority subject to your expressed preferences. Family disagreement can be mitigated by clear documentation of preferences and by communication of those preferences to family before crisis. Ethics consultations are available at most Georgia hospitals to mediate disagreements.

Q23: Can dual-eligibles get hospice in a nursing facility?

Yes, with coordination. Medicare hospice covers the hospice services. Medicaid covers nursing facility room and board for full-benefit dual-eligibles. This combination makes hospice in nursing facility settings feasible for low-income beneficiaries.

Q24: How do I prepare for end-of-life decisions while still healthy?

(1) Complete a Georgia advance directive designating a health care agent and expressing treatment preferences; (2) Discuss your preferences with your family, primary care physician, and designated agent; (3) Distribute copies; (4) Consider Five Wishes (an alternative advance directive format that may be easier to discuss); (5) Revisit periodically and update as life circumstances change.

Q25: Where can I get help with end-of-life planning in Georgia?

Contact GeorgiaCares SHIP at 1-866-552-4464 for free Medicare counseling. Contact Aging with Dignity Five Wishes at 1-888-594-7437 for an alternative advance directive format. Contact Hospice Foundation of America at 1-800-854-3402. Contact Hospice Georgia at 770-637-4427. Contact your physician for ACP discussion. Contact Brevy at brevy.com for educational content on Medicare end-of-life care. :::

::: cta Georgia and federal contacts for Medicare end-of-life care

• Medicare: 1-800-MEDICARE (1-800-633-4227); 24/7
• Palmetto GBA Jurisdiction J MAC: 1-877-567-9230
• GeorgiaCares SHIP (free Medicare counseling): 1-866-552-4464
• Georgia DCH Medicaid Member Services: 1-866-211-0950
• Georgia POLST Coalition: 678-553-3500
• Aging with Dignity Five Wishes: 1-888-594-7437
• Hospice Foundation of America: 1-800-854-3402
• National Hospice and Palliative Care Organization (NHPCO): 1-800-658-8898
• Compassion and Choices: 1-800-247-7421
• Hospice Georgia: 770-637-4427
• Center for Medicare Advocacy: 1-860-456-7790
• Medicare Rights Center: 1-800-333-4114
• Kepro QIO (Beneficiary and Family Centered Care): 1-844-455-8708
• Atlanta Legal Aid: 404-377-0701
• Georgia Legal Services: 1-800-498-9469
• Eldercare Locator: 1-800-677-1116
• Social Security: 1-800-772-1213
• VA Benefits: 1-800-827-1000
• HHS OCR (civil rights complaints): 1-800-368-1019
• 211 Georgia: 211
• Georgia Department of Public Health: 404-657-2700 :::