CMS Hospice Billing Guidelines: FY 2026 Rates, Claims, and Caps

Medicare hospice billing guidelines are set out in 42 CFR Part 418 and the Medicare Claims Processing Manual, and they tie every dollar of payment to three things: a properly certified terminal illness, a timely Notice of Election, and a claim that identifies each day of care at one of four defined levels. Miss any of those, and the day is not billable. For FY 2026, per-diem rates run from about $182 for later routine home care days to nearly $1,200 for general inpatient care, with a 2.6 percent update over FY 2025.¹

FY 2026 Payment Rates by Level of Care

Medicare pays a prospective per-diem for each day the patient is enrolled, and the amount depends on which of four levels of care the patient received that day. The rates below are national base rates before the hospice wage index adjustment for the patient’s geographic area.

Routine Home Care (Revenue Code 0651)

Routine Home Care is the baseline. It covers days when the patient receives hospice services in the home, a nursing facility, or an assisted living facility, and does not need around-the-clock intervention. Most hospice days fall here. RHC uses a two-tier rate:¹

Days 1 through 60: $230.83 per day
Days 61 and beyond: $181.94 per day

The higher rate in the first 60 days reflects heavier resource use at admission, when care plans are being set up and symptoms are often less controlled. In the last seven days of life, when the patient is discharged due to death, RHC days can also qualify for a Service Intensity Add-on. The SIA pays the Continuous Home Care hourly rate ($69.76 in FY 2026) for each hour a registered nurse or social worker provides direct patient care that day, capped at four hours, which can add up to $279.04 on top of the RHC rate.²

Continuous Home Care (Revenue Code 0652)

Continuous Home Care covers brief crisis periods when a patient needs intensive care at home to avoid hospitalization. A CHC day requires at least eight hours of direct patient care within a midnight-to-midnight window, and nursing must make up the majority of those hours. Hospice aide and homemaker time can supplement but cannot dominate. The eight hours do not have to be consecutive.³

CHC is billed hourly at $69.76, with a full 24-hour day paying $1,674.29 in FY 2026.¹ It is the highest-paying level and draws disproportionate audit attention. The record has to identify the crisis, document the skilled services hour by hour, and explain why a lower level of care could not have handled it.

Inpatient Respite Care (Revenue Code 0655)

Respite care is short-term inpatient placement to give the primary caregiver a break. Medicare covers up to five consecutive days at a time, after which the patient generally returns to routine home care. Respite stays can be repeated after a break. The FY 2026 rate is $532.48 per day.¹

General Inpatient Care (Revenue Code 0656)

General Inpatient Care is for pain control or acute symptom management that cannot be delivered at home. It happens in a hospital, a freestanding hospice inpatient unit, or a qualifying skilled nursing facility. The FY 2026 rate is $1,199.86 per day.¹

GIP is not built for long stays. The documentation has to identify the specific crisis event, show what failed at a lower level of care, and explain each day why inpatient-level monitoring is still needed. Once symptoms are controlled, the patient should move back to routine home care, and discharge planning should begin on the day of admission.

Certifying the Patient as Terminally Ill

A patient qualifies for the Part A hospice benefit only after a physician certifies that life expectancy is six months or less if the disease runs its normal course.⁴ The benefit runs in two initial 90-day periods followed by an unlimited number of 60-day periods, with no lifetime cap.⁵

The first period needs written certifications from two physicians: the hospice medical director (or the physician member of the interdisciplinary group) and the patient’s attending physician, if one has been designated. Each certification must include a brief narrative of the clinical findings supporting the six-month prognosis. That narrative is the single most scrutinized piece of documentation in hospice audits, and boilerplate language is a common reason claims are denied. Written certification can be completed up to 15 calendar days before the election takes effect. If the hospice cannot get a signed written certification in time, it may rely on a verbal certification for up to two calendar days, but the signed version must be in the record before any claim is submitted.⁶

Subsequent periods need only the hospice physician’s recertification. Starting with the third benefit period (the first 60-day period), a hospice physician or nurse practitioner must conduct a face-to-face encounter with the patient no more than 30 days before the new period begins and attest to it. An attending physician who is not employed by the hospice cannot satisfy this requirement.⁷

Every physician who certifies or recertifies must be enrolled in Medicare or have formally opted out. That applies to the hospice physician and to any patient-designated attending. If a certifying physician is neither enrolled nor opted out, Medicare will not pay the claim.⁸

Election and the Notice of Election

Before any billing can happen, the patient or their representative has to sign a hospice election statement identifying the hospice, the attending physician (if any), and the effective date. It also has to acknowledge that hospice care is palliative rather than curative, describe cost-sharing, and give contact information for the Beneficiary and Family Centered Care Quality Improvement Organization.⁹ By signing, the patient waives Medicare coverage for treatment of the terminal illness and related conditions, except for services delivered by the hospice itself or by an independent attending physician. Regular Medicare continues to cover unrelated conditions.

If the hospice decides certain drugs, conditions, or services are unrelated to the terminal illness and therefore not covered under the hospice benefit, it must offer the patient an election statement addendum listing those items with a clinical explanation. The addendum matters for billing because it is what allows non-hospice providers to bill Medicare separately for the unrelated items.

Within five calendar days of the admission date, the hospice must file a Notice of Election with its Medicare Administrative Contractor. The NOE is electronic and includes the hospice’s provider number, the beneficiary’s identifier, the effective date, and the attending physician’s information. Miss the five-day window and Medicare will not pay for any day between admission and the date the MAC accepts the late NOE; the hospice absorbs those days and must flag them on the claim with occurrence span code 77.¹⁰ CMS encourages hospices to file as soon as possible after admission rather than waiting.

When a patient is discharged alive or revokes the election, the hospice must file a Notice of Termination/Revocation with the MAC within five calendar days of the effective date, unless a final claim for that patient has already been submitted. A patient can revoke at any time for any reason, effective on a date the patient chooses.¹¹

Submitting Claims

Claims go to the MAC electronically using the UB-04 institutional claim form (CMS-1450) or its electronic equivalent.¹² Each claim covers a specific billing period and identifies every day of care with its level-of-care revenue code (0651, 0652, 0655, or 0656).¹³ Hospices typically bill monthly or biweekly.

The outside deadline is 12 months from the date of service. After that, the hospice cannot collect, with narrow exceptions for situations like retroactive Medicare entitlement or errors made by a Medicare contractor or HHS employee acting within the scope of their authority. A rejected claim has to be corrected and resubmitted inside the same window.¹³

Days that are non-billable because of a late NOE, untimely recertification, or another coverage gap still appear on the claim, tagged with occurrence span code 77. They generate no payment.¹⁰

Attending Physician Billing Under Part B

When a patient elects hospice, nearly all professional services related to the terminal illness become the hospice’s responsibility. The exception is an attending physician who is not employed by, and not paid under arrangement with, the hospice. That physician can continue billing Medicare Part B directly for professional services related to the terminal illness.¹⁴

Two modifiers separate hospice-related services from everything else:

GV: attending physician professional services related to the terminal illness, when the physician is not employed by the hospice.
GW: any provider, for services unrelated to the terminal illness.

Claims submitted for a hospice patient without either modifier will be denied. Only the physician’s direct professional work goes to Part B; lab, imaging, and other technical components go to the hospice. For services with both components, the attending physician bills Part B for the professional component and looks to the hospice for the technical one. Payments to independent attending physicians do not count against the hospice aggregate cap.¹⁴

What the Patient Owes

The hospice benefit has no deductible, and Medicare covers virtually all hospice services without cost-sharing. There are two exceptions: a small copayment for outpatient prescription drugs related to the terminal illness, and a 5 percent coinsurance for inpatient respite care, capped at the Part A inpatient hospital deductible for that year. The hospice bills and collects both amounts from the patient.¹³¹⁵

One boundary that surprises families: Medicare hospice does not cover room and board for a patient living in a nursing facility. The facility’s daily room charge continues while the patient is on hospice, and someone has to pay it. Medicaid may cover it for dual-eligible patients; otherwise the patient or family does.⁵

Documentation and Audit Exposure

Hospice audits come back to one question: does the record support the terminal prognosis and the level of care billed? The physician narrative is the first thing a reviewer reads. Objective data holds up on appeal; boilerplate does not. Reviewers want functional decline scores, weight trends, lab values, and specific evidence of disease progression, not a restatement of the diagnosis.

Level-of-care documentation gets the second-hardest look. GIP and CHC claims both require evidence that the same care could not have been delivered at a lower level. For GIP, that means naming the precipitating crisis, describing what was tried at home, and documenting each day why the inpatient setting is still required. For CHC, the record has to show that nursing was the predominant service during the eight-hour minimum.

The Hospice Aggregate Cap

Medicare limits the total per-diem payments any single hospice can receive in a cap year through the Hospice Aggregate Cap. The cap equals an annually adjusted per-beneficiary amount multiplied by the number of Medicare beneficiaries served during the cap year. For FY 2026, the per-beneficiary amount is $35,361.44.¹

Hospices self-calculate their cap liability each year between December 31 and February 28 following the end of the cap year. Payments above the cap have to be returned. Independent attending physician payments billed under Part B do not count toward the cap, but every per-diem payment across all four levels of care does. Hospices with a high proportion of long-stay patients are especially exposed, because the RHC rate drops after day 60 while the beneficiary keeps counting toward the cap calculation.¹⁶

Discharge Notice and Patient Appeals

Before a hospice discharges a patient, it must deliver a Notice of Medicare Non-Coverage at least two calendar days before covered services are scheduled to end. This is a calendar-day requirement, not a 48-hour clock. If the last covered day is a Friday, the NOMNC should go out no later than Wednesday.

A patient who thinks services are ending too soon can request an expedited appeal from the BFCC-QIO in their state by noon on the day before the termination date on the NOMNC. Services continue during the review. If the QIO upholds the discharge, the patient owes nothing for services delivered before the coverage end date on the NOMNC.¹⁷

1
Federal Register. Medicare Program FY 2026 Hospice Wage Index and Payment Rate Update
2
eCFR. 42 CFR Part 418 Subpart G – Payment for Hospice Care
3
eCFR. 42 CFR 418.302 – Payment Procedures for Hospice Care
4
eCFR. 42 CFR Part 418 – Hospice Care
5
Medicare.gov. Hospice Care Coverage
6
eCFR. 42 CFR 418.22 – Certification of Terminal Illness
7
CMS. Face-to-Face Requirement Affecting Hospice Recertification
8
CMS. Hospice Certifying Enrollment – Questions and Answers
9
eCFR. 42 CFR 418.24 – Election of Hospice Care
10
Centers for Medicare & Medicaid Services. Transmittal R3577CP – Medicare Claims Processing
11
eCFR. 42 CFR Part 418 Subpart B – Eligibility, Election and Duration of Benefits
12
Centers for Medicare & Medicaid Services. Institutional Paper Claim Form CMS-1450
13
CMS. Medicare Claims Processing Manual – Hospice
14
Centers for Medicare & Medicaid Services. CMS Transmittal 304 – Medicare Claims Processing
15
Centers for Medicare & Medicaid Services. Hospice
16
eCFR. 42 CFR 418.309 – Hospice Aggregate Cap
17
Medicare.gov. Fast Appeals