Medicaid is a joint federal and state program providing health coverage to individuals with limited income and resources. This program offers a comprehensive benefit for hospice care, which is a specialized form of palliative treatment for people with a terminal illness, typically defined as a prognosis of six months or less. While Medicaid covers the full scope of medical and support services associated with hospice, coverage for “room and board” is complex and depends entirely on the setting where care is delivered. The distinction between paying for medical services and paying for a patient’s daily living costs determines Medicaid’s financial responsibility for housing and meals.
The Core Medicaid Hospice Coverage
The standard Medicaid Hospice Benefit is a comprehensive package of services focused on comfort and quality of life, rather than curative treatment. This benefit requires a physician’s certification that the patient is terminally ill and that the services are necessary for managing the illness and its related conditions. When a patient elects the hospice benefit, Medicaid pays a per diem rate to the certified hospice agency to cover all necessary services.
This payment covers the interdisciplinary team, including physician services, skilled nursing care, and medical social services. The benefit also covers necessary medical equipment and all medications required for pain and symptom control related to the terminal diagnosis. Furthermore, the hospice agency provides aide services, physical and occupational therapies, and counseling services for both the patient and the family, including bereavement support.
Why Residential Room and Board is Excluded
The exclusion of room and board stems from the fundamental difference between medical care and custodial care within federal healthcare programs. Room and board encompasses costs like food, rent, utilities, and general personal assistance, which are categorized as daily living expenses. The standard Medicaid Hospice Benefit is specifically designed to cover the medical services provided by the hospice team.
When a patient receives hospice services in their private home, an assisted living facility, or a residential group home, the costs of housing and daily maintenance remain the patient’s responsibility. The hospice benefit covers the medical services, medications, and equipment, but it does not pay the patient’s rent or mortgage. This principle holds true even in an assisted living setting, where the resident or their private resources are expected to cover the non-medical costs of residence.
Covered Exceptions for Short-Term Stays
Despite the general exclusion, Medicaid covers room and board during two specific, short-term situations requiring institutional placement due to medical or caregiver necessity. The first exception is General Inpatient Care (GIP), authorized when a patient experiences acute symptoms or pain that cannot be managed effectively in any other setting.
GIP is a temporary, high-acuity level of care provided in a Medicare-certified facility, such as a hospital or a specialized hospice inpatient unit. During a GIP stay, Medicaid covers the room, board, and all services because the patient is receiving intensive, around-the-clock medical intervention. The second exception is Inpatient Respite Care, designed to provide temporary relief for the patient’s primary caregiver.
Respite care allows the patient to be admitted to an approved facility for a brief period, typically limited to a maximum of five consecutive days. This coverage ensures the caregiver can rest without interrupting the patient’s care. For both GIP and Respite Care, the room and board costs are included in the facility’s payment, recognizing the short-term, necessary nature of the institutional stay.
State Medicaid’s Role in Long-Term Care
Medicaid provides a separate mechanism for covering room and board when a patient resides in a Skilled Nursing Facility (SNF) and is eligible for institutional long-term care. This coverage is provided through the state’s Medicaid Long-Term Services and Supports (LTSS) program, not the federal hospice benefit itself. To qualify, a patient must meet strict financial and functional eligibility criteria, often requiring a determination that they need a nursing facility level of care.
If a patient elects the hospice benefit while residing in a Medicaid-covered nursing facility, the payment structure becomes split. The hospice agency receives the standard per diem payment for specialized medical and palliative services. Simultaneously, the hospice agency is mandated to pass a room and board payment through to the nursing facility. This payment is typically calculated at 95% of the state’s established Medicaid rate for the SNF’s custodial care portion. This arrangement ensures that the patient’s daily living costs in the nursing home are covered, while the hospice team provides the terminal illness-related care.