In-home nursing or hospice: which does your family need?

What is the real difference between hospice and in-home nursing?

The real difference between hospice and in-home nursing is not the setting or the nurse. It is who has to sign, who pays, and what the care is trying to accomplish. Hospice requires a physician to certify a terminal prognosis and is largely paid for by Medicare. Private duty nursing requires no prognosis and is paid for privately, by the family.

CMS sets the hospice rule in Chapter 9 of the Medicare Benefit Policy Manual, section 10, revised 5 March 2026. To elect the benefit, a person must be entitled to Medicare Part A and be certified as terminally ill, which CMS defines as a medical prognosis that life expectancy is 6 months or less if the illness runs its normal course. Medicare.gov's Hospice Care Coverage page, checked 11 August 2026, adds two more conditions: you accept comfort care instead of care meant to cure the illness, and you sign a statement choosing hospice instead of other Medicare-covered treatments for it.

Private duty nursing has none of that machinery. There is no prognosis to certify, no election statement, and no benefit period, because Medicare is not the payer: Medicare.gov's Long Term Care Coverage page states that Medicare does not pay for long-term care and that you pay all costs for non-covered services. Setting is not the dividing line either, since Medicare.gov states hospice can usually be provided wherever the person lives, including an assisted living facility or a nursing home. That is the trade. Hospice is largely covered and tightly gated. Private duty nursing is ungated and privately paid. Our in-home private duty nursing page sets out what the second option actually involves.

Who actually decides whether someone qualifies for hospice?

A physician decides, and no nurse can do it for you. That surprises families who assume the hospice agency or the hospital case manager makes the call. So can the nurse practitioner who has known your father for a decade sign it?

No. CMS states in Chapter 9, section 20.1 of the Medicare Benefit Policy Manual that no one other than a medical doctor or doctor of osteopathy can certify or recertify an individual as terminally ill, and that nurse practitioners and physician assistants cannot certify.

CMS adds two layers that explain why a referral can take days rather than hours. Since 1 October 2009, the certifying physician has had to write an individualized narrative of the clinical findings supporting the six-month prognosis, and CMS states it cannot contain check boxes or standard language used for all patients. For recertifications on or after 1 January 2011, a hospice physician or hospice nurse practitioner must also have a face-to-face encounter with the patient before the third benefit period and before each one after that.

The practical consequence for a family in a hurry: the hospice gate is a physician's signature and a written clinical narrative. You cannot speed it up by hiring a better nurse, and the person still needs somebody in the house tonight.

Does choosing hospice mean my parent has six months to live?

No. Six months is the prognosis a physician has to certify to open the benefit. It is not a countdown clock and not a cap on how long hospice can last. So what happens if your mother is still here in month eight?

Nothing automatically. CMS states in Chapter 9 of the Medicare Benefit Policy Manual that predicting life expectancy is not always exact and that the fact that a beneficiary lives longer than expected is not in itself cause to terminate benefits. Coverage runs in two 90-day benefit periods followed by an unlimited number of 60-day periods, as long as a physician recertifies.

The number that should worry you runs the other way. MedPAC's March 2026 Report to the Congress reports that among Medicare hospice decedents in 2024, the median lifetime length of stay was 19 days, while the average of 99.6 days was pulled upward by a long tail of very long stays. At the 10th percentile, stays were 2 days. At the 25th percentile, 5 days. A quarter of hospice patients received less than a week of it.

MedPAC also reports that hospice is now the majority path at the end of life: 52.9 percent of Medicare decedents used it in 2024, a new high, up from 51.7 percent in 2023. If part of what frightens you is a sense that hospice is drastic or unusual, the data says otherwise.

Can we change our minds after choosing hospice?

Yes, at any time and in writing. CMS states that an individual or representative may revoke the election of hospice care at any time in writing, and that there is no waiting period before re-electing hospice later. CMS also states that a hospice cannot revoke a patient's election and should not request or demand that a patient revoke.

What the election does commit you to is a goal of care. CMS section 20.2.1 requires the patient or representative to acknowledge the palliative rather than curative nature of treatment, and that certain Medicare services are waived by the election. Under 42 CFR 418.24(f)(2), the patient waives Medicare payment for services related to the terminal condition furnished by someone other than the designated hospice.

The rest of Medicare does not switch off. Medicare.gov states that Original Medicare will still pay for covered benefits for health problems that are not part of your terminal illness and related conditions, though you will owe any deductible and coinsurance that apply. You keep your own physician if you name that person the attending medical professional, and you may change hospice providers once during each benefit period.

One distinction is worth getting right before anyone signs. The National Institute on Aging explains that palliative care and hospice are not the same thing, and that the difference is curative treatment. In palliative care a person does not have to give up treatment that might cure a serious illness, and it can begin at diagnosis. In hospice, attempts to cure are stopped. If your family wants comfort while treatment continues, you are describing palliative care, not hospice. That NIA page was last reviewed 14 May 2021.

How many hours a week is hospice actually in the house?

About 3.6 hours, on average. MedPAC's March 2026 Report to the Congress found that in 2024 Medicare hospice patients received an average of 3.9 in-person visits per week and 218 minutes of in-person visit time per week, which works out to about 55 minutes a visit. Nurse visits averaged 1.8 per week and aide visits 1.9 per week.

That number reframes the whole decision. Hospice at home is intermittent visiting care, not a continuous presence. MedPAC reports that routine home care, the visiting model, accounted for 98.8 percent of Medicare-covered hospice days in 2024.

The intensive levels exist, but they are rare and tightly bounded. MedPAC reports that in 2023 and 2024, only 2 percent of hospice patients received even one day of continuous home care and 4 percent even one day of inpatient respite care. CMS limits continuous home care in section 40.2.1 to a period of crisis and requires a minimum of 8 hours of care in a 24-hour day, more than half of it nursing.

Respite is bounded too. CMS section 40.1.5 states that inpatient respite care may be provided only on an occasional basis, may not be reimbursed for more than 5 consecutive days at a time, and cannot be provided at all to hospice patients who reside in a facility such as a long term care nursing facility. CMS also states it is not appropriate to bill Medicare for general inpatient care days where the individual's caregiver support has broken down, unless the coverage requirements for that level are otherwise met. A caregiving crisis is not, by itself, what the hospice benefit is built to solve.

The National Institute on Aging puts the consequence in one sentence: although hospice provides a lot of support, the day-to-day care of a person dying at home is provided by family and friends, with the hospice team coaching them. Hospice is designed around a family caregiver who is present. If nobody in your family can be that person, hospice may still be the right clinical choice, and the hours will still be yours to fill. Our page on overnight, 24-hour and live-in nursing explains how families cover the hours that visiting care does not.

What does hospice cost a family, and what does it not cover?

Hospice care itself costs nothing at the point of care for most families, but it is not completely free. Medicare.gov states that you pay nothing for hospice care from a Medicare-approved hospice provider, that you pay a copayment of up to $5 for each prescription for outpatient drugs for pain and symptom management, and that you may pay 5 percent of the Medicare-approved amount for inpatient respite care. Medicare does not cover room and board, so an assisted living or nursing home bill keeps arriving.

Both copays have ceilings in CMS policy. Section 30.1 of Chapter 9 caps drug coinsurance at $5.00 per prescription. Section 30.2 caps respite coinsurance for a hospice coinsurance period at the inpatient hospital deductible for the year the period began, which the Federal Register notice published 19 November 2025 set at $1,736 for calendar year 2026, up from $1,676 in 2025. It is a ceiling, not a bill to expect.

The exclusion that catches families is room and board, which Medicare.gov states is not covered whether you get hospice at home, in a nursing home, or in a hospice inpatient facility. If your parent lives in assisted living, hospice arrives at no cost and the facility invoice does not change.

What Medicare pays the hospice explains the visiting model. Under the CMS final rule published 5 August 2025 and effective 1 October 2025, the fiscal year 2026 routine home care rate is $230.83 per day for days 1 to 60 and $181.94 from day 61 onward. Continuous home care is $1,674.29 for a full 24 hours, which CMS calculates as $69.76 per hour, and only during a crisis. A per diem paid for a day of care is not an hourly rate for a shift of care.

If we are not ready for hospice, what will Medicare pay for at home?

Less than most families expect, and almost never the thing they are actually asking for. The benefit people confuse with private duty nursing is Medicare home health, and the first question is usually whether it will send a nurse to stay overnight.

No. Medicare.gov's Home Health Services Coverage page states plainly that Medicare does not pay for 24-hour-a-day care at your home. Hospice has one level of care that puts a nurse in the home for long stretches, continuous home care, but CMS restricts it to periods of crisis, and MedPAC reported that only 2 percent of hospice patients received even one day of it in 2023 and 2024.

The same Medicare.gov page, checked 11 August 2026, lists the other exclusions: home meal delivery, homemaker services such as shopping and cleaning unrelated to your care plan, and custodial or personal care that helps with bathing, dressing, or using the bathroom when that is the only care you need. Home health also requires the patient to be homebound and to need only part-time or intermittent skilled care, a ceiling Medicare.gov defines as up to 8 hours a day combined and a maximum of 28 hours a week, or up to 35 hours a week for a short time if your provider decides it is necessary.

Read that limit twice, because it is counterintuitive. Under Medicare home health, needing more care can disqualify you rather than qualify you. Medicare.gov's Long Term Care Coverage page closes the last door: Medicare does not pay for long-term care, and you pay all costs for non-covered services. We go through that gap in detail on does Medicare cover private duty nursing.

One thing about who is telling you this: WholeHealth Concierge is not a Medicare-certified home health agency and does not bill Medicare. Nothing here describes coverage we can arrange for you.

What does private duty nursing actually cost in California?

The California median is $110 per hour, according to the CareScout Cost of Care Survey 2025, which collected rates from July through November 2025 and published its median cost tables on 2 March 2026. The same survey puts the California median for a non-medical caregiver at $40 per hour and the median private duty nurse visit rate at $208. WholeHealth Concierge does not publish its own rates.

National medians in the same tables are $35 per hour for a non-medical caregiver, $90 per hour for a private duty nurse, and $160 per nurse visit. CareScout collected more than 25,000 rates for the 2025 survey and merged homemaker and home health aide services into one non-medical caregiver category because prices had converged.

Annualized, the two rates diverge sharply. CareScout's annual medians for in-home care are built on the non-medical caregiver rate and a 44-hour week: $80,080 nationally, up 3 percent year over year, and $91,520 in California, which is that $40 California caregiver rate at 44 hours. CareScout does not publish an annualized private duty nurse figure. At the same 44 hours a week, California's $110 nurse median works out to about $251,680 a year (our arithmetic on CareScout's figures). For comparison, its 2025 California annual medians are $84,000 for assisted living, $146,000 for a semi-private nursing home room, and $182,135 for a private room.

Two honest observations. These are medians for a market, not quotes. And a licensed nurse costs meaningfully more than a non-medical caregiver because the scope of practice is different: California Business and Professions Code section 2725 defines the registered nurse scope to include care ensuring the safety, comfort, personal hygiene, and protection of patients, administration of medications and therapeutic agents ordered by, and within the scope of licensure of, a physician, dentist, podiatrist, or clinical psychologist, and observation of signs and symptoms with appropriate reporting or referral. If what your family needs is companionship, help with bathing, and meals, you are looking at the caregiver rate, not the nursing rate.

If the person you are caring for is recovering rather than declining, our sourced page on what in-home care costs after a stroke works through the same medians against the Medicare hour caps, and long-term care insurance for home nursing covers the policy route.

Can a family use hospice and a private duty nurse at the same time?

We do not know, and we are not going to pretend otherwise. It is a fair question once you have seen the visit numbers, and the CMS hospice manual and the Medicare.gov hospice pages do not address privately paid nursing alongside hospice.

Here is what can be said. 42 CFR 418.24(f)(2), referenced in section 20.2.1 of Chapter 9, waives Medicare payment for services related to the terminal condition furnished by someone other than the designated hospice. That is a payment rule: it tells you what Medicare will not pay for. It is not, on its face, a statement about what a family may purchase with its own money.

So take the questions to the hospice instead, before anyone signs an election statement.

• Does your agency have a policy on families privately hiring additional caregivers or nurses?
• How do you want a private caregiver to coordinate with the hospice plan of care?
• What does your agency consider related to the terminal condition, since that is the phrase the Medicare payment waiver turns on?
• Who do we call first at two in the morning, you or the private nurse?

Get those answers from the hospice that would be signing the election, in writing if you can. If the paperwork and the phone calls are the part your family cannot carry, that coordination work is nurse-led care management.

Which one does your family actually need?

Answer three questions honestly and the choice usually makes itself. What is the goal of care, has a physician certified a prognosis, and who is in the house at two in the morning.

Hospice is likely the right answer if the illness is advanced and treatment aimed at cure is no longer what your family wants, if a physician will certify the prognosis CMS requires, and if the priority is expert comfort, symptom management, and a team on call. It is largely covered by Medicare and per CMS it is revocable in writing at any time.

Private duty nursing is what you are looking for when the gap is hours rather than expertise. Nobody is available overnight and the person cannot safely be left alone. Somebody needs to be present for a shift, not a visit. A parent is coming home after a hospital stay and the family wants a licensed nurse watching for the first week, which is the situation our hospital discharge advocacy page covers. No physician has certified a terminal prognosis and nobody wants one, because the goal is still recovery. Or hospice is in place and doing its job, and the family still cannot staff the remaining 164 hours of the week. Before arranging that combination, put the questions in the section above to the hospice, because the CMS hospice manual and the Medicare.gov hospice pages do not address privately paid nursing alongside the hospice benefit.

Families on Medi-Cal should know California runs hospice on the same structure: the California Department of Health Care Services states that any Medi-Cal recipient certified by a physician as having a life expectancy of six months or less may elect hospice in lieu of normal Medi-Cal coverage for services related to the terminal condition.

And if the honest answer is that your family needs hospice and cannot afford private nursing on top of it, do not let cost keep you from the hospice benefit. That decision belongs with the treating physician. There is no version of this page where we would rather you buy hours you cannot afford than use a benefit you have already paid for.

Why is a nursing practice explaining hospice to you?

Because we do not sell hospice and legally cannot, so we have nothing to gain by talking you out of it. That is not modesty, it is a licensing fact. If you are wondering whether we provide it, here is the short answer.

No. WholeHealth Concierge is a private duty nursing practice and is not a licensed hospice agency, and under California Health and Safety Code section 1747, an operator that was not already running a hospice as of January 1, 1991 may not establish or operate one without first obtaining a license. WholeHealth Concierge is also not a Medicare-certified home health agency and does not bill Medicare.

California also has a moratorium on new hospice licenses: Health and Safety Code section 1751.70 states that from 1 January 2022 until 1 January 2027, or one year after emergency regulations are adopted under section 1753.1, the department shall not issue a new license to operate a hospice agency, subject to the exceptions in that section. That moratorium is scheduled to lapse on 1 January 2027 and this page will be reviewed then. Either way, the licensure requirement in section 1747 is what prevents us from providing hospice.

WholeHealth Concierge is a nurse-led private duty nursing practice based in Chino Hills, California, serving families in Orange County, Los Angeles County, San Bernardino County, and parts of Riverside County. Our vetted RN and LVN staff work under the clinical oversight of Meagan Williams, RN, BSN, CCRN. If your family needs hospice, the right next call is to the treating physician and a Medicare-certified hospice agency, not to us. If your family needs hours of licensed nursing presence at home that hospice and Medicare home health do not cover, that gap is what we exist to fill.

Everything here is general education about how these benefits work, not medical advice about your family member, and coverage rules change. Every figure is attributed and dated so you can check it yourself.