Georgia Medicare Hospice Benefit: Coverage Guide

When a doctor confirms a parent has six months or less to live, the Medicare Hospice Benefit can take over their comfort care at home, usually at little or no cost to the family.1 For Georgia families facing a terminal diagnosis, it delivers a full team: nursing, physician oversight, social work, counseling, aide services, medications, equipment, and grief support for the family after the death. It is a Part A benefit anchored in Section 1812(a)(4) of the Social Security Act and the hospice regulations at 42 CFR Part 418, and it trades curative treatment of the terminal illness for care focused on comfort, dignity, and quality of life in the final months.

This guide is written for the person making the decision. It explains who qualifies, what electing hospice waives and what it keeps, the four levels of care, how long coverage can last, what it costs, how room and board works for a dual-eligible parent in a Georgia nursing facility, and the practical steps to begin.

In This Guide

• Does Medicare Cover Hospice?
• How Long Can You Stay on Hospice?
• The Four Levels of Care
• What Hospice Costs
• Hospice in a Nursing Facility
• How Georgia Families Access Hospice
• Frequently Asked Questions
• Learn More

Does Medicare Cover Hospice in Georgia, and Who Qualifies?

Yes. The eligibility rules and the covered services are federal, so they read the same in Georgia as in every other state. What is local is the money and the clinical criteria for some diagnoses: Medicare's daily rates are adjusted for area wages, and the Medicare Administrative Contractor serving Georgia publishes its own coverage criteria for non-cancer diagnoses (both covered below). To qualify, a Medicare beneficiary must be certified by a physician as terminally ill, meaning a life expectancy of 6 months or less if the illness runs its normal course, and must choose comfort care instead of curative treatment for the terminal illness.1

The 6-month prognosis is a clinical judgment, not a prediction or a guarantee. Some patients live well beyond 6 months and keep qualifying at each recertification; others decline more quickly. Eligibility is based on the person's overall condition, comorbidities, functional decline, and disease trajectory, not a stopwatch.

Who Certifies the Terminal Illness

For the first 90-day period, two physicians must certify the terminal illness under 42 CFR 418.22: the hospice medical director (or another physician member of the hospice interdisciplinary group), and the attending physician, if the beneficiary has one. For each period after that, only the hospice medical director (or another interdisciplinary-group physician) must recertify.

The certifying physician also writes a brief narrative explaining the clinical findings that support a 6-month prognosis. It must be a written attestation the physician composes, reflecting the patient's individual circumstances, not a checkbox or generic language.

Hospice for Non-Cancer Diagnoses

Many families do not realize hospice covers far more than cancer. For non-cancer conditions, the Medicare Administrative Contractor publishes Local Coverage Determinations (LCDs) that describe when a diagnosis supports a hospice prognosis. Common ones cover:

• End-stage congestive heart failure with New York Heart Association Class IV symptoms and treatment-refractory disease
• End-stage chronic obstructive pulmonary disease with breathlessness at rest and recurrent infections
• End-stage dementia at Functional Assessment Staging (FAST) stage 7c or worse, with medical complications
• End-stage renal disease in a patient who declines or stops dialysis
• End-stage liver disease with clinical decompensation

For Georgia, hospice claims are processed by the Medicare Administrative Contractor for the region, and its LCD criteria apply. A hospice medical director or the referring physician can tell a family whether a specific diagnosis meets the local criteria.

Timing of Certification

Written certification must be in place no later than 2 calendar days after hospice care starts. A hospice may begin services on a verbal certification as long as the written certification is signed within those 2 days. If it is not, Medicare will not pay for the days before the written certification was completed.

Electing Hospice: What the Waiver Means

The hospice election is the legal act of choosing hospice and accepting its terms: the beneficiary chooses comfort care instead of curative treatment for the terminal illness.1 Under 42 CFR 418.24, the beneficiary (or a representative, if the beneficiary lacks capacity) signs an election statement that names the specific hospice, acknowledges the palliative rather than curative nature of the care, acknowledges that certain Medicare services are waived, and sets an effective date. The effective date may be the date of signature or any later date, but never earlier.

What the Waiver Covers, and What It Doesn't

Electing hospice waives the right to Medicare payment for care that treats the terminal illness and its related conditions. It does not waive coverage for everything else. Care unrelated to the terminal illness continues to be covered by Original Medicare (or a Medicare Advantage plan) exactly as before.

Consider a Georgia hospice patient with end-stage pancreatic cancer:

• Related, covered by hospice: opioid pain medication, anti-nausea drugs, palliative radiation for bone pain, hospice nursing and aide visits, social work, chaplaincy, and family bereavement support.
• Unrelated, covered by Original Medicare or Medicare Advantage: treatment for an injury from a fall, routine dental or vision care, or ongoing management of long-standing, well-controlled high blood pressure.

Drugs commonly used for hospice symptom management, such as analgesics, anti-nausea medicines, anti-anxiety medicines, and laxatives, are presumed related to the terminal illness unless the record documents otherwise.

One point that surprises families with a Medicare Advantage plan: the hospice benefit itself is paid by Original Medicare, not by the MA plan, even though the person stays enrolled in that plan.1 The MA plan keeps covering care unrelated to the terminal illness on its usual terms, so the plan card and the hospice both stay in the picture.

Revoking Hospice

Under 42 CFR 418.28, a beneficiary may revoke the hospice election at any time with a signed statement giving the revocation date. On revocation, the person forfeits the days left in the current benefit period and returns to Original Medicare or Medicare Advantage for the terminal illness. They may re-elect hospice later, and there is no limit on the number of times a person can revoke and re-elect. A beneficiary who wants to pursue curative treatment for the terminal illness must revoke first, because the waiver otherwise stays in effect and Medicare will deny the curative claims.

A beneficiary may also change to a different hospice once during a benefit period under 42 CFR 418.30, documented with a signed statement, without it counting as a revocation.

How Long Can You Stay on Medicare Hospice?

There is no lifetime limit on hospice. Coverage is organized into benefit periods, and it continues as long as the terminal prognosis is recertified. Under 42 CFR 418.21, the periods are an initial 90-day period, a second 90-day period, and then an unlimited number of 60-day periods, in that order.2 A physician must recertify that the patient remains terminally ill at the start of each new period, and recertification must be in place no later than 2 calendar days after the period begins.

The Face-to-Face Encounter

Beginning with the third benefit period (the first 60-day period) and before each period after it, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with the patient to support recertification.2 The encounter must:

• Assess the patient's clinical condition and document the findings that support continued eligibility
• Be conducted by a hospice physician or a hospice-employed or hospice-contracted nurse practitioner, not the outside attending physician
• Be completed no more than 30 calendar days before the period begins

If a nurse practitioner conducts the encounter, the certifying physician composes an attestation confirming they used the encounter findings in determining eligibility. If the encounter is missed, the patient becomes ineligible from the missed date until it is completed, and those gap days are not Medicare-payable. CMS recognizes narrow "exceptional circumstances," but they are the exception.

The Four Levels of Hospice Care

Under 42 CFR 418.302, Medicare pays hospices a daily rate that varies with the level of care the patient needs each day. There are four levels.4

1. Routine Home Care (RHC)

Routine Home Care is the most common level and covers the great majority of hospice days. It applies when the patient is in their home, which may be a private residence, an assisted living community, or a nursing facility, and does not need continuous nursing care. Since a payment reform that took effect in fiscal year 2016, RHC is paid on a two-tier structure: a higher rate for days 1 through 60, and a lower rate for day 61 and beyond, to better match payment to the actual intensity of care over time.

Hospices may also receive a Service Intensity Add-on for in-person visits by a registered nurse or social worker during the last 7 days of the patient's life, paid at the continuous home care hourly rate (up to a daily limit) to reward intensive support at the very end.

2. Continuous Home Care (CHC)

Continuous Home Care is provided during a crisis to control acute symptoms and keep the patient at home rather than transferring to a facility. To qualify for the CHC rate, a minimum of 8 hours of care must be furnished in a day, and that care must be predominantly nursing care.4 CHC ends when the crisis resolves and the patient returns to routine home care, or when the symptoms cannot be managed at home and general inpatient care is needed.

3. Inpatient Respite Care (IRC)

Inpatient Respite Care gives the primary caregiver short-term relief. It is furnished in a Medicare-certified facility and may not be provided for more than 5 days in a row at a time; payment for the sixth and any later consecutive day is made at the routine home care rate.4 The purpose is caregiver rest, not symptom management. Non-consecutive respite stays may be arranged again later as the caregiver needs them.

4. General Inpatient Care (GIP)

General Inpatient Care is furnished in a Medicare-certified inpatient facility for pain or symptom management that cannot be handled in another setting. It is the highest-acuity level, used for crises like uncontrolled pain, intractable nausea, or severe agitation. It is not for caregiver relief, which is the role of respite. General inpatient and respite days together are limited, but the limit applies to the hospice rather than to any one patient: under 42 CFR 418.302(f), and Section 1861(dd)(2)(A)(iii) of the Social Security Act behind it, total inpatient care days furnished to a hospice's Medicare patients may not exceed 20 percent of the total days those patients had hospice elections in effect. At the end of each cap year the Medicare Administrative Contractor calculates the limitation and recoups payment for the hospice's inpatient days above that 20 percent share. It is not a personal ceiling on a patient's inpatient days, so an individual still receives general inpatient or respite care whenever it is clinically indicated.5 GIP ends when symptoms stabilize and the patient can step down to a lower level.

What the Georgia Medicare Hospice Benefit Covers

Under 42 CFR 418.202, the Medicare hospice benefit covers an interdisciplinary package of services:

• Nursing services by or under a registered nurse
• Physician services by the hospice medical director or a designated physician
• Medical social services by a qualified social worker
• Counseling, including dietary, spiritual, and bereavement counseling
• Hospice aide and homemaker services under RN supervision
• Physical, occupational, and speech therapy for palliative purposes
• Medical supplies, drugs, and durable medical equipment related to the terminal illness
• Short-term inpatient care, including respite and general inpatient care
• Bereavement support for the family after the death

The Interdisciplinary Group

Under Section 1861(dd) of the Social Security Act and 42 CFR 418.56, every hospice must maintain an interdisciplinary group that includes at minimum a physician, a registered nurse, a social worker, and a pastoral or other counselor. This group develops and updates the plan of care, coordinates services across disciplines, and addresses the physical, emotional, social, and spiritual needs of the patient and family.

Bereavement Support

Under 42 CFR 418.64, the hospice must make bereavement services available to the family for up to a year after the patient's death.3 These may include counseling, support groups, memorial services, and follow-up calls, and they are included in the hospice payment at no separate charge. Many families do not know this support exists and never use it, so it is worth asking the hospice's bereavement coordinator what is offered.

Hospice and Medicare Part D

Coordinating hospice with Medicare Part D for medications is one of the most confusing parts of the benefit at the pharmacy counter. The rule is straightforward once you see the split: hospice pays for drugs related to the terminal illness (as part of its daily payment), and Part D continues to cover drugs unrelated to it (with standard Part D cost-sharing).

To keep Part D from paying for drugs that hospice should cover, Part D plans typically require prior authorization for four classes commonly used in hospice: analgesics, anti-nausea medicines, laxatives, and anti-anxiety medicines. When a prescription in one of these classes is filled, the prior-authorization prompt starts a quick conversation among the family, the hospice, and the prescriber about whether the drug is related to the terminal illness (hospice pays) or unrelated (Part D pays). For hospice-related drugs, the out-of-pocket charge is no more than $5 per prescription.1

What the Georgia Medicare Hospice Benefit Costs

For families, hospice is close to free: no more than $5 per prescription for symptom-management drugs, and 5% of the Medicare-approved amount for inpatient respite care.1 There is no deductible and no charge for the routine home visits, equipment, or supplies related to the terminal illness.

Medicare pays the hospice, not the family. Rates are set each year by CMS and adjusted for local wages. For fiscal year 2026 (October 1, 2025 through September 30, 2026), the national base Medicare per-diem rates, before the local wage adjustment, are approximately $230.83 per day for Routine Home Care days 1 to 60 and $181.94 for day 61 and after; $69.76 per hour for Continuous Home Care (a full 24-hour day is $1,674.29); $532.48 per day for Inpatient Respite Care; and $1,199.86 per day for General Inpatient Care.6 These reflect the 2.6% fiscal year 2026 payment update for hospices that report the required quality data.

The Hospice Aggregate Cap

Medicare limits a hospice's total Medicare payments for a year through an annual aggregate cap under 42 USC 1395f(i)(2) and 42 CFR 418.309. It is not a ceiling on what Medicare will spend on any one patient. For the fiscal year 2026 cap year, the per-beneficiary cap amount is $35,361.44; CMS multiplies that amount by the number of Medicare beneficiaries in the hospice program that cap year to get the hospice's total cap, and payments to the hospice that exceed that total are overpayments and must be refunded.7

This is a limit on the hospice provider, not on the individual patient. It does not cap any one person's days or care. An individual can stay on hospice indefinitely as long as they keep meeting the clinical criteria and are recertified.

Hospice in a Nursing Facility for Dual Eligibles

When a parent who has both Medicare and Georgia Medicaid (a "dual eligible") elects hospice while living in a nursing facility, both programs play a role, and understanding the split can save a family thousands of dollars.

• Medicare hospice pays the hospice its daily rate for hospice services. For a patient in a nursing facility, the level is usually Routine Home Care, because the facility counts as the patient's home for hospice purposes.
• Georgia Medicaid covers room and board. Under 42 USC 1396a(a)(13)(B), the state plan must pay an additional amount for room and board equal to at least 95% of the rate it would otherwise have paid the nursing facility for that resident. CMS describes the methodology this way: the room-and-board per diem is reimbursed to the hospice provider at 95% of the nursing-facility rate, less the resident's post-eligibility contribution toward the cost of their own care, and the hospice provider is responsible for passing that payment through to the facility.8

The Georgia Department of Community Health administers Medicaid hospice. For a dual-eligible parent in a Georgia nursing facility, Medicare pays the hospice its per-diem, and Georgia Medicaid pays the hospice a room-and-board amount equal to 95% of the nursing-facility rate less the resident's own share of cost, which the hospice forwards to the facility.8 That share of cost is the resident's own income, minus the deductions the federal post-eligibility rules require, applied toward the cost of care as their patient liability. Georgia's Personal Needs Allowance for a Medicaid resident in a nursing facility or institutionalized hospice is $70 per month, and the deductions taken before the rest is counted also include a monthly maintenance needs allowance for a spouse still living at home, dependent and family allowances, and health-insurance premiums including Medicare premiums, deductibles, and coinsurance.9 Without the Medicaid room-and-board payment, the family would owe the facility's full private-pay rate, which runs to thousands of dollars a month.

How Georgia Families Access Hospice

Starting hospice is not complicated, but it moves quickly once a family decides. Here is the path from recognizing that hospice may be appropriate to the care beginning at home.

Worked Examples

The following examples are hypothetical and for illustration only. Real coverage depends on a physician's certification and each hospice's assessment.

Example #1: Margaret, 78, Atlanta, terminal cancer, Routine Home Care

Margaret has Stage IV pancreatic cancer with metastases. After a third hospitalization for pain, her oncologist recommends hospice, with a prognosis of about 3 to 4 months. She enrolls with a hospice in Atlanta; the hospice medical director and her oncologist both certify the terminal illness, and she signs the election statement.

Routine Home Care begins. A nurse visits three times a week, an aide helps with bathing, and a social worker supports Margaret and her husband. The hospice covers her pain and symptom medications through its pharmacy; her long-standing cholesterol medication, unrelated to the cancer, stays on her Part D plan. In her last week, the hospice provides Service Intensity Add-on visits from the nurse and social worker. After she dies, the hospice provides bereavement support to her family for up to a year.

Example #2: Robert, 82, Savannah, heart failure, Continuous Home Care

Robert has New York Heart Association Class IV congestive heart failure and has been hospitalized repeatedly despite optimal treatment. His cardiologist explains that hospice covers non-cancer diagnoses and that his condition meets the local cardiopulmonary criteria. He enrolls with a Savannah hospice, which now manages his heart-failure medications as related to the terminal illness.

Robert lives about 6 months on hospice. He is recertified after each 90-day period, and before the third period a hospice nurse practitioner conducts the face-to-face encounter at his home. When he develops acute pulmonary edema in his final week, the hospice starts Continuous Home Care for a day of intensive symptom management, then steps him back down to Routine Home Care.

Example #3: Linda, 75, Macon, dementia, face-to-face recertification

Linda has advanced Alzheimer's dementia at FAST stage 7c: bedbound, minimally verbal, dependent for all daily activities, with recent aspiration pneumonia and continued weight loss. Her daughter, her healthcare proxy, enrolls her with a Macon hospice, and the medical director and Linda's geriatrician certify the terminal illness under the dementia criteria.

Linda's election begins in the fall. She is recertified through the first and second 90-day periods. Before the third period, within 30 days of the recertification date, the hospice nurse practitioner visits and documents her worsening swallowing, weight loss, and recent infection. The hospice medical director reviews the findings and composes an attestation supporting recertification. Each later 60-day period will require its own face-to-face encounter.

Example #4: Henry, 85, Athens, dual-eligible nursing facility hospice

Henry has lived in an Athens nursing facility for three years with advanced dementia, and he is dual-eligible for Medicare and Georgia Medicaid. As he declines, the facility physician recommends hospice, and his daughter agrees and signs the election as his proxy. He receives Routine Home Care while staying in the facility, which counts as his home.

The money works like this: Medicare hospice pays the hospice its Routine Home Care per-diem; Georgia Medicaid pays the hospice a room-and-board amount equal to 95% of the Georgia nursing-facility rate, less Henry's own share of cost8; the hospice forwards that payment to the facility; and Henry's income, minus allowed deductions and his $70 monthly Personal Needs Allowance, is that share of cost.9 Without the Medicaid room-and-board pass-through, the family would face the facility's full private-pay rate, often several thousand dollars a month. After Henry dies, the hospice provides bereavement support to his family for up to a year.

The Statutory and Regulatory Framework

Families and clinicians who understand the law behind hospice can recognize when something is being handled wrong and advocate effectively. The benefit rests on a layered foundation.

• Section 1812(a)(4) of the Social Security Act (42 USC 1395d(a)(4)) establishes hospice as a covered Part A benefit, alongside inpatient hospital, skilled nursing facility, and home health services.
• Section 1814(a)(7) (42 USC 1395f(a)(7)) sets the certification and election framework: payment is made only for a beneficiary who is terminally ill, has filed an election with a Medicare-certified hospice, and has physician certification of the terminal illness.
• Section 1861(dd) (42 USC 1395x(dd)) defines hospice care and the interdisciplinary group.
• Section 1814(i) establishes the payment methodology, including the aggregate cap, the Hospice Quality Reporting Program (added by the IMPACT Act of 2014), and the face-to-face encounter requirement (added by Section 3132 of the Affordable Care Act of 2010).
• 42 CFR Part 418, the Hospice Conditions of Participation, is the implementing regulation, covering eligibility and election, patient-care and organizational conditions, covered services, and payment.

The benefit was created by the Tax Equity and Fiscal Responsibility Act of 1982, made permanent by the 1985 COBRA law, and restructured into its current form of two 90-day periods then unlimited 60-day periods by the Balanced Budget Act of 1997.2 The Medicare Modernization Act of 2003 created Part D and its hospice coordination, and the Affordable Care Act of 2010 added the face-to-face encounter and physician narrative.

Common Mistakes

1. Confusing hospice with palliative care. Palliative care can run alongside curative treatment at any stage. Hospice requires a 6-month terminal prognosis and the waiver of curative treatment for the terminal illness.

2. Waiting too long to elect. Many families enroll only in the final days, far short of what the benefit allows. Earlier election means more time for symptom control, family support, and preparation.

3. Believing hospice means "giving up." Hospice is active care: pain and symptom management, emotional and spiritual support, and family bereavement care. It is care focused on quality of life, not the absence of care.

4. Misunderstanding the waiver. Hospice waives curative treatment only for the terminal illness and related conditions. Care for unrelated conditions stays covered by regular Medicare.

5. Missing the face-to-face encounter. A missed encounter before the third or a later 60-day period creates days that are not Medicare-payable until it is completed.

6. Confusing Continuous Home Care with General Inpatient Care. CHC is intensive home nursing during a crisis (at least 8 hours, predominantly nursing). GIP is facility-based care for symptoms that cannot be managed at home.

7. Confusing the aggregate cap with an individual limit. The cap applies to the hospice provider's total payments, not to any one patient. Individuals can stay on hospice indefinitely while they meet the criteria.

8. Not realizing Part D continues. After election, Part D still covers medications unrelated to the terminal illness, subject to standard rules and prior authorization for commonly hospice-related classes.

9. Believing election is permanent. A beneficiary can revoke at any time, forfeiting only the current period's remaining days, and can re-elect later.

10. Missing bereavement support. Families are entitled to bereavement services for up to a year after the death, and many never use them simply because no one told them.3

Learn More

Find personalized help understanding hospice coverage for your family at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.