Newsroom · Sioux Falls

Medicare Hospice Benefit in Sioux Falls 2026: What Part A Covers, What It Doesn't, and How Your Plan Fits In

Near-zero cost-sharing, an unlimited benefit, and a rule that reshapes Medicare Advantage — here's what Sioux Falls beneficiaries need to know before it matters most.

Big Sioux Benefits Data Desk

Published July 14, 2026 · 10 min read · Sourced from CMS.gov & Medicare.gov

The Medicare hospice benefit is one of the most comprehensive in the entire program — and one of the least discussed until families need it. Part A covers a full team of care: nurses, physicians, social workers, counselors, and home health aides — plus nearly all medications related to the terminal condition. The cost-sharing is minimal by design, because Congress wrote the hospice benefit to let people focus on comfort rather than bills.

What trips people up are the three eligibility gates, the way benefit periods work (no lifetime cap, but recertification required), and a rarely explained rule that changes the picture for Medicare Advantage enrollees. Every figure in this article comes from public federal sources: the CDC PLACES county data, Medicare.gov hospice coverage guidance, the CMS Medigap policy guide, and CMS county enrollment data. No invented numbers, no pressure estimates.

Who Qualifies for Medicare Hospice Care

Four conditions must all be true before Medicare Part A hospice coverage begins. Missing any one of them means the hospice benefit is not yet available — though it can be elected later when the criteria are met.

Source: Medicare.gov — Hospice care; 42 U.S.C. § 1395x(dd) (Medicare hospice benefit definition).

The most common misconception is that the 6-month rule is a strict deadline. It is a medical certification of your prognosis if the illness follows its natural course — not a hard cutoff. If you are still living after 6 months and continue to meet the criteria, your physician can recertify for additional periods. People have remained on Medicare hospice for years.

How the Medicare Hospice Benefit Periods Work

The benefit structure is more generous than most people realize. There is no lifetime day or hour limit on Medicare hospice — the program is designed so that recertification keeps coverage going as long as the terminal-illness standard is met.

Source: Medicare.gov — Hospice care; 42 C.F.R. § 418.21.

At the start of each new benefit period, the hospice medical director (or physician designee) must recertify that your prognosis still meets the 6-month standard. If your condition improves and you no longer meet the standard, hospice ends — but you can re-elect later if the situation changes. The ability to revoke at any time, and to return to regular Medicare immediately upon revocation, is one of the few truly unconditional rights in the Medicare program.

What Part A Pays For — and the Two Small Cost-Sharing Items

Medicare Part A covers a comprehensive set of hospice services, most at $0 to you. The two modest cost-sharing items are a $5 maximum per outpatient drug prescription for symptom control or pain, and 5% coinsurance for short-term inpatient respite care. Here is the complete service table:

Source: Medicare.gov — Hospice care; 42 C.F.R. §§ 418.400, 418.204.

Inpatient respite care deserves special attention for family caregivers. When a family member needs a break from providing care at home, Medicare Part A hospice allows up to 5 consecutive days of inpatient respite care at a Medicare-approved facility — such as a hospital, skilled nursing facility, or inpatient hospice facility — at just 5% coinsurance. There is no limit on the number of times respite care can be used across benefit periods; only the 5-consecutive-day limit per respite period applies.

Which Conditions in Sioux Falls Most Often Lead to Hospice

Not every chronic condition leads to hospice — but three in particular are the primary drivers of hospice enrollment nationally: cancer, chronic obstructive pulmonary disease (COPD), and heart disease. All three are present at meaningful rates in Minnehaha County, according to CDC PLACES data for local adults:

Source: CDC PLACES: Local Data for Better Health, County 2023 (2023), Minnehaha County adults.

Among Minnehaha County's 39,532 Medicare beneficiaries, these conditions translate to real populations. The 8.0% cancer prevalence means roughly 3,160 local Medicare beneficiaries are living with a cancer diagnosis. COPD and coronary heart disease each affect thousands more. Depression at 22.3% is also significant: mental health is an explicitly covered service under Medicare hospice, and the intersection of serious illness and depression is common enough that hospice's counseling and social work benefits frequently address it.

None of this means a person with COPD or heart disease is imminently entering hospice. Chronic conditions progress at different rates, and many people manage them for years. The point is that hospice planning is relevant to a significant share of the local Medicare population — not a remote possibility for someone else.

Medicare Advantage and Hospice: The Part A Carve-Out Rule

This is the rule most Medicare Advantage enrollees are not aware of, and it matters significantly for the 11 Medicare Advantage plans available to Minnehaha County beneficiaries in 2026.

When a Medicare Advantage enrollee elects hospice, the hospice benefit is paid by Original Medicare Part A — not by the Medicare Advantage plan. The MA plan is "carved out" of the hospice equation. This means:

• All hospice-related services (nursing, physician, drugs for the terminal condition, respite, counseling) are delivered and paid under Part A, with the same $0/$5/5% cost-sharing as someone on Original Medicare.
• Your Medicare Advantage plan continues to provide coverage for conditions unrelated to the terminal diagnosis. If you have a heart condition that's separate from your terminal illness, your MA plan covers those visits and treatments as it normally would.
• Your MA monthly premium keeps running even though hospice services go through Part A. This is often a surprise for families. The five standard PPOs in Sioux Falls range from $0 to $80/month — none of those premiums pause during hospice.

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County 2026.

The practical takeaway: the hospice benefit is essentially the same under Original Medicare and under Medicare Advantage. The carve-out rule creates a level playing field because hospice reverts to Part A regardless of your plan type. Where your plan type does matter is in the coverage for unrelated conditions during hospice — and in whether you're also paying a Medigap premium alongside Part A (for those on Original Medicare + Medigap) or a lower MA premium that keeps running.

Medigap Plans and Hospice Cost-Sharing: What Each Plan Covers

For beneficiaries on Original Medicare plus a Medigap supplement, the hospice benefit interacts directly with the Medigap plan's hospice coverage column. The cost-sharing at stake is modest — the $5 drug copay and 5% respite coinsurance — but it's worth knowing how each plan handles it.

Source: CMS — Choosing a Medigap Policy (Publication 02110); CMS standardized Medigap plan matrix, 42 C.F.R. § 403.205.

Plans A, B, D, G, M, and N all cover 100% of Part A hospice coinsurance/copayments — meaning the $5 drug copay and 5% respite coinsurance are both paid by the plan. Plans K and L take a cost-sharing approach, covering 50% and 75% respectively, which leaves small but real out-of-pocket amounts for high-cost respite stays. Plans K and L also carry their own annual out-of-pocket maximums ($7,220 and $3,610, respectively) that limit total exposure across the whole year.

For most people considering hospice planning, Plan G is the broadest coverage available to post-2019 enrollees — it covers 100% of hospice coinsurance, all Part A hospital costs, and Part B coinsurance, with the only exposure being the $257 annual Part B deductible. Plan N covers hospice fully but leaves $20 office visit and $50 ER copays for non-hospice care. The right plan depends on your full coverage picture, not just hospice in isolation.

The Drug Coverage Split During Hospice

When you elect hospice, drug coverage splits into two tracks — and understanding which drugs go on which track prevents surprise bills:

• Drugs related to the terminal condition: Covered under Part A hospice, with a maximum $5 copay per prescription for outpatient drugs used for symptom control or pain relief. The hospice pharmacy is arranged by the hospice agency. You do not submit these through your Part D plan.
• Drugs for conditions unrelated to the terminal diagnosis: Continue through your Part D drug plan exactly as before. If you take medication for high blood pressure (very common given Minnehaha County's 31.7% hypertension rate) or arthritis (22.9%) that is not related to your terminal condition, those claims continue through Part D.

The 2026 $2,100 Part D out-of-pocket cap is significant here. Before this cap existed, people on hospice for a terminal illness could still face uncapped drug costs for their other chronic conditions. With the cap now in place, total Part D spending for non-hospice drugs is capped at $2,100 per year regardless of which plan you're on — adding a meaningful financial protection during an already difficult period.

One important nuance: what counts as "related to the terminal condition" is a judgment call made by the hospice medical team. If there's any uncertainty about whether a medication falls under Part A hospice or Part D, ask the hospice team to clarify in writing before the prescription is filled.

What Medicare Hospice Does Not Cover

The hospice benefit is designed specifically for comfort-focused care. Several categories of care and cost fall outside it:

• Curative treatment for the terminal condition. By electing hospice, you waive Medicare coverage for curative treatments aimed at the terminal diagnosis — surgery to cure, chemotherapy or radiation aimed at cure (palliative chemo/radiation for symptom control may be covered), and similar aggressive interventions. You can revoke hospice at any time to return to curative treatment.
• Room and board in a nursing facility. If you receive hospice care in a nursing home, Medicare does not pay the nursing home's room and board. You pay that cost directly (or through Medicaid if you qualify). Medicare only covers the hospice team's visits and services — not the nursing home's room fees.
• Services unrelated to the terminal condition. Treatment for conditions completely separate from your terminal diagnosis continues under your regular Medicare coverage (Part A/B or your MA plan) — not under the hospice benefit.
• 24-hour continuous home care except in crisis periods. Hospice does not cover round-the-clock home care as a routine matter. It does cover "continuous home care" (a higher-level crisis care category) for a short period if you're in a medical crisis, but routine overnight custodial care is not included.

What to Watch for Hospice Care in Sioux Falls in 2026

1. Ask about hospice early, not only at the end. Medicare allows hospice consultation at no charge — you don't have to commit to electing it to get information. Local providers like Sanford and Avera both have palliative care and hospice teams who can explain your options while you still have time to plan.
2. If you're on Medicare Advantage, understand the carve-out before a crisis. The Part A carve-out means your MA plan's network rules change during hospice — services go through Part A hospice, not your MA plan. Know this in advance so transitions don't create delays in care.
3. Audit your drug list before electing hospice. Know which of your medications are related to the terminal condition (Part A hospice, ≤$5 copay) and which are for other conditions (Part D, subject to the $2,100 cap). Get it documented.
4. For Medigap enrollees: verify your plan's hospice column. Most current plans cover 100% of hospice cost-sharing. If you're on Plan K or L, the 50%/75% hospice coverage means small out-of-pocket amounts for respite care — budget for that.
5. Know the revocation right. At any point — if a new treatment becomes available, if your condition improves, or if you simply change your mind — you can revoke the hospice election and return to regular Medicare immediately. The option is never off the table.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references CMS enrollment data, CDC PLACES county health statistics, CMS Medigap plan guidance, and published Medicare benefit rules — built by Strategic AI Architects. Cost-sharing figures ($5 drug copay, 5% respite coinsurance) are published federal regulatory amounts from 42 C.F.R. § 418.400 and § 418.204, as referenced on Medicare.gov. This article is education, not advice; confirm your specific plan, benefit rules, and eligibility with a licensed agent or Medicare.gov. We take no payment from any carrier to feature a plan.