The 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) made further provisions for hospice benefits under Medicare. A very important step that this legislation addressed was the sunset clause under the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) that established hospice as a benefit under Medicare. “Congress established the Medicare hospice benefit as both a cost-containment mechanism to limit the program’s high cost for beneficiaries in their last year of life and a quality improvement tool to improve care for the dying” (Gage et al., 2000).

        When the benefit was introduced in 1982 there was a sunset clause attached to the bill in order to make sure that this benefit was going to be beneficial and cost-effective.  If it did not meet this criterion then coverage would end in 1986. Under TEFRA the provisions for hospice such as benefit periods, levels of care, and specific staffing requirement of hospices were established.

        COBRA confirmed hospice as a benefit under Medicare and recognized that a hospice benefit should be permanently established in order to provide citizens with the right to choose hospice in their remaining days.  Rather than shifting ideologies or practices, the provisions in COBRA actually strengthened and expanded on the original intent of the hospice benefit, which was to address the way our culture views the dying process. Rather than leaving a dying person in isolation, often to suffer, the hospice philosophy recognizes the importance of support. The act addresses this philosophy of providing for a team approach to care that included doctors, nurses, social workers, the patient and the family. In addition to focusing on the patient’s needs, special attention was placed on the needs of the family. Bereavement services are provided to the family for up to one year after the death of the patient.

        Under this act “all Medicare Part A beneficiaries are eligible for hospice care if their physician certifies that the beneficiary is terminally ill (defined as a life expectancy of 6 months or less), the beneficiary chooses to receive care from hospice instead of standard Medicare benefits for the terminal illness, and the care is provided by a Medicare- participating hospice provider” (Health Care Financing Review, 1998). Another provision of the 1986 COBRA act was that terminally ill patients in nursing homes would be covered under the Medicare hospice benefit, thus recognizing that nursing homes are often the residence of terminally ill patients. The third and final provision gave states the option to include a hospice benefit under Medicaid.