Medicaid coverage for hospice in a nursing home involves coordinating two separate funding streams. Medicaid often pays for long-term custodial care in a nursing facility for eligible individuals. Hospice is a distinct benefit focused on end-of-life comfort care. The interaction between these two systems creates a specialized dual-payment mechanism. This coordination ensures the patient receives both necessary comfort care and coverage for their long-term residence.
The Hospice Benefit and Services Covered
Hospice care shifts the focus from curative treatment to palliative care, emphasizing comfort and quality of life for terminally ill individuals. Eligibility requires a physician to certify the patient has a prognosis of six months or less. The comprehensive hospice benefit is delivered by an interdisciplinary team and covers all services related to the terminal illness.
The benefit covers clinical care provided wherever the patient resides, including the nursing home. Services include nursing care, physician services, medications for symptom management, medical equipment, and supplies. It also covers social worker services, spiritual counseling, and short-term respite or inpatient care when medically necessary. Importantly, the hospice benefit does not cover the expenses of routine daily living or room and board in the long-term care facility.
Medicaid Coverage of Nursing Home Residency Costs
Medicaid is a joint federal and state program assisting low-income individuals with medical costs, including long-term custodial care. For nursing home residents, Medicaid covers the costs associated with room, board, and assistance with activities of daily living. These services include personal care, meals, and general supervision.
Medicaid is a primary payer for nursing home expenses for those who meet the state’s financial criteria for income and resources. This funding covers the cost of the patient’s physical location and routine, non-hospice care needs. This role is distinct from covering the specialized clinical services provided by the hospice team.
The Dual Payment System for Hospice in a Nursing Home
When a Medicaid-eligible patient in a nursing home elects the hospice benefit, a dual payment system is activated. The hospice agency receives a daily per diem payment covering all specialized hospice clinical services. This per diem is paid regardless of whether the source is Medicare or Medicaid.
The hospice per diem does not include the cost of the patient’s room and board. Since the patient remains in the nursing home, Medicaid continues to cover the patient’s custodial care costs. However, the mechanism requires the hospice agency to manage a specific financial responsibility.
The state Medicaid program reimburses the hospice provider for the patient’s room and board. This reimbursement is set at 95% of the lowest nursing facility per diem rate. The hospice agency must then pass this room and board payment directly to the nursing facility. This system ensures the nursing home is compensated for daily needs, while the hospice agency is compensated for specialized end-of-life care.
Requirements for Patient Eligibility and Enrollment
To access the combined Medicaid and hospice benefit, a patient must meet specific criteria for both services. The individual must be financially eligible for state Medicaid, including limits on income and assets. They must also reside in a Medicaid-certified nursing home.
The patient must receive certification from a physician and the hospice medical director confirming they are terminally ill, with a life expectancy of six months or less. The patient or representative must formally elect the hospice benefit by signing an election statement. This action waives the patient’s right to receive Medicaid coverage for curative treatments related to the terminal illness.
The patient can revoke the hospice benefit at any time and resume coverage for curative treatments. Successful coordination requires the selected hospice provider to have a contract with the nursing facility. Continuous communication between the nursing home staff and the hospice team is necessary to ensure all patient needs are met.