The 4 levels of hospice care under Medicare, explained

Not clinically reviewed. Informational only, not billing, legal or clinical advice. Check the linked primary source and your Medicare Administrative Contractor.

Medicare hospice has four levels of care: routine home care, continuous home care, inpatient respite care and general inpatient care. A hospice is paid for one level on any given day. Routine home care accounts for nearly 99 percent of hospice days; the other three cover short-term needs, like a symptom crisis or a caregiver's break.

Key facts - Medicare pays a hospice a daily rate based on 1 of 4 levels of care (CMS, page last modified Sept. 8, 2026, checked Nov. 2, 2026). - Only one level is paid for any particular day, and continuous home care counts only when at least 8 hours of care are given that day (42 CFR 418.302, checked Nov. 2, 2026). - Routine home care makes up nearly 99 percent of all hospice days (MedPAC, October 2024). - Respite care runs up to 5 days in a row, and you may owe 5% of the Medicare-approved amount for it (Medicare.gov, checked Nov. 2, 2026).

Families usually hear about "levels of care" when something changes: a hospice says a patient needs more nursing at home during a crisis, or a worn-out caregiver is offered a short break. The four levels are Medicare's categories for those situations. They decide where care happens, how intensive it is, and which daily rate Medicare pays the hospice. If you're still sorting out what hospice is, start with our guide to home health vs. home care vs. hospice.

What are the four levels of hospice care?

CMS's hospice payment page (last modified Sept. 8, 2026; checked Nov. 2, 2026) says Medicare generally pays a hospice a daily rate for each day a patient is enrolled, no matter how many services were given that day, including days with none. That daily payment is based on one of four levels:

Sources: CMS and 42 CFR 418.302, both checked Nov. 2, 2026.

MedPAC, the commission that advises Congress on Medicare payment, puts it simply in its Payment Basics on hospice (revised October 2024): the four levels differ by where care is given and how intensive it is, and a patient's level can change during a hospice stay as their needs change.

What is routine home care?

Routine home care is the everyday level. Under 42 CFR 418.302(b)(1) (eCFR up to date as of Oct. 29, 2026), it's a day the patient is at home and isn't getting continuous care. CMS notes that "home" can be a private home, a skilled nursing facility or an assisted living facility, and calls routine home care the level given when the patient isn't in crisis.

It is by far the most common level. MedPAC's October 2024 Payment Basics says routine home care accounts for nearly 99 percent of all hospice days. Routine home care has two daily rates, a higher one for days 1 to 60 and a lower one from day 61. In the last 7 days of life, Medicare also pays extra for registered nurse and social worker visits, up to 4 hours a day (MedPAC; 42 CFR 418.302(b)(1)). We don't repeat the dollar amounts here because CMS updates them each fiscal year. Our story on FY 2027 hospice payment rates and the cap has the current figures.

When is continuous home care used?

Continuous home care is for a crisis at home. The regulation defines it as a day the patient isn't in an inpatient facility and gets care at home that is "predominantly" nursing care on a continuous basis. Hospice aide or homemaker services can be added. It can be given "only during brief periods of crisis" and only as needed to keep the patient at home (42 CFR 418.302(b)(2)).

Two rules shape it:

• The 8-hour minimum. At least 8 hours of care must be given on a day to qualify. Below that, the hospice is paid the routine home care rate for the day (42 CFR 418.302(e)(3)–(4)).
• Hourly payment. The continuous home care rate is divided by 24, and the hospice is paid for the hours actually given. MedPAC adds that the hours are counted in a 24-hour day starting at midnight, and that a nurse must give half of them.

That's why continuous home care isn't the same as 24-hour care at home. It's a short-term, crisis-only level, and how many hours a day it covers depends on what the patient needs.

What is inpatient respite care?

Respite care is for the caregiver. Under 42 CFR 418.302(b)(3), it's a day the patient gets care in an approved facility on a short-term basis for respite. CMS describes it as up to 5 days in a row to give the caregiver a rest, and MedPAC describes it as facility care for up to five days to give an informal caregiver a break.

The 5-day limit is built into payment. Respite can't be given for more than 5 days in a row, and Medicare pays the sixth and any later day at the routine home care rate (42 CFR 418.302(e)(5)).

Respite is also one of the few places a Medicare hospice patient may owe something. Medicare.gov (checked Nov. 2, 2026) says you may pay 5% of the Medicare-approved amount for inpatient respite care, and that your copayment can't be more than the inpatient deductible amount. CMS describes the same coinsurance as a daily amount equal to 5% of Medicare's payment for a respite day.

What is general inpatient care?

General inpatient care is for symptoms that can't be managed anywhere else. The regulation defines it as a day the patient gets care in an inpatient facility for pain control or acute or chronic symptom management that can't be managed in other settings (42 CFR 418.302(b)(4)). MedPAC describes it as short-term facility care.

Medicare.gov says that if your hospice team decides you need inpatient care at a hospital, the team must arrange the stay. If it doesn't, you might have to pay the entire cost of the hospital care. Medicare.gov also tells patients to contact the hospice team before getting hospital outpatient care, such as an emergency room visit, or ambulance transportation, or they might have to pay the entire cost.

How does Medicare pay for each level?

Each level has its own fixed payment rate set by CMS, adjusted for local wages (42 CFR 418.302(c); MedPAC). The payment rules that matter most to families and new staff:

• One level per day. Medicare pays for only one level of care for any particular day (42 CFR 418.302(e)(2)).
• Routine home care is the default. On a day the patient isn't an inpatient, the hospice gets the routine home care rate unless continuous care reaches 8 hours (418.302(e)(3)).
• Inpatient days and the day you go home. The general inpatient or respite rate is paid for the admission day and each later inpatient day, but not the discharge day. That day is paid at the home care rate, unless the patient dies as an inpatient (418.302(e)(5)).
• A limit on inpatient days. Across all of a hospice's Medicare patients, general inpatient and respite days can't be more than 20 percent of total hospice days. The Medicare Administrative Contractor checks this at the end of each cap period (418.302(f)). This limit applies to the hospice's totals, not to any one patient.
• Patient cost-sharing is small. Under CMS's page, the patient may owe up to $5 per prescription for pain and symptom drugs during routine or continuous home care, and nothing for drugs during general inpatient or respite care. The respite coinsurance is described above.

Current dollar rates for every level, plus the aggregate cap, are in our FY 2027 rates story. Hospice billing staff may also want our explainer on long-stay claim edits returning in April 2027.

What should families ask the hospice?

The sources above suggest these questions:

• Who decides when my loved one's level changes, and how will you tell us? Medicare.gov says the hospice team decides on short-term inpatient and respite care and arranges it.
• What counts as a crisis for continuous home care, and how many hours of nursing can you provide? The rule requires at least 8 hours a day, mostly nursing, and only during brief crises.
• If we need respite, which facility would you use, and what would we owe? Respite is up to 5 days in a row, with a possible 5% copayment capped at the inpatient deductible amount.
• If symptoms get worse, where would general inpatient care happen? Ask which hospitals or inpatient units the hospice uses, since the hospice must arrange the stay.
• What won't you cover? Medicare.gov says you can ask for an addendum to the hospice election statement listing items, services and drugs the hospice won't cover because they're unrelated to the terminal illness. Our story on the now-mandatory election statement addendum explains the rule hospices follow since Oct. 1, 2026.

Frequently asked questions

How long can hospice respite care last? Up to 5 days in a row. CMS describes inpatient respite care as up to 5 consecutive days in an approved facility, and under 42 CFR 418.302 Medicare pays any sixth or later day at the routine home care rate.

Does hospice provide 24-hour care at home? Not as a rule. Continuous home care, the most intensive level at home, is meant only for brief periods of crisis. It is paid only when at least 8 hours of care, mostly nursing, are given in a day, and it is paid by the hour (42 CFR 418.302; MedPAC).

What does respite care cost the patient? Medicare.gov says you may pay 5% of the Medicare-approved amount for inpatient respite care, capped at the inpatient deductible amount. CMS says the respite coinsurance is a daily amount.

Can a hospice bill two levels on the same day? No. Under 42 CFR 418.302(e)(2), Medicare pays for only one level of care for any particular day.

Who decides which level of care a patient gets? The hospice. Medicare.gov says Medicare covers a facility stay when the hospice team determines you need short-term inpatient or respite care and arranges it. MedPAC notes the level can change during a stay as the patient's needs change.

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Sources were opened and checked Nov. 2, 2026. Rules and coverage can change; the linked primary sources control. Home Health Brief corrects errors under its published corrections policy.

This item has not been clinically reviewed. It is general information, not clinical, billing or legal advice.

Drafted with AI assistance from primary sources. Written and edited by the Home Health Brief newsroom under Monsaur Othman's editorial standards. Read how we use AI, our editorial policy and our corrections policy.