End-of-life care involves costs beyond medical treatment, particularly those associated with daily living. These non-medical charges are often called “hospice room and board” and apply when a patient resides in a facility rather than their private home. Coverage for these costs is conditional, depending on the distinction between funding for medical care and funding for daily custodial services. The answer is determined by the patient’s financial eligibility and the specific care setting.
Understanding the Cost of Hospice Room and Board
The term “room and board” (R&B) in hospice care refers to costs separate from the medical services provided by the hospice team. These charges cover the expenses of daily living for a patient residing in an institutional setting, such as a nursing facility or an assisted living residence. R&B costs include facility fees, rent, utilities, routine meals, housekeeping, and laundry services.
Room and board also covers assistance with activities of daily living (ADLs), such as bathing, dressing, and feeding, provided by the facility’s staff. These daily living expenses are distinct from the covered hospice benefit, which pays for nursing care, medications, durable medical equipment, and physician services related to the terminal illness.
How Medicaid Steps In Where Medicare Ends
Medicare is the primary federal program covering the medical component of hospice care, but it explicitly excludes room and board costs for patients receiving routine home care, even if that “home” is a nursing facility or a hospice residence. This exclusion is a significant financial barrier for patients who cannot remain in their private residence. Medicare only covers R&B on a temporary basis when a patient requires a higher level of care, such as continuous home care or general inpatient care, which is short-term and crisis-driven.
Medicaid, the joint federal and state program, addresses this gap for low-income individuals who are financially eligible. It is the specific payer for custodial room and board costs when a hospice patient resides in a certified nursing facility. This coverage is provided under a contractual agreement where the hospice organization manages the patient’s medical care, and Medicaid pays the facility’s room and board rate.
The payment mechanism is often a per diem rate set by the state. This rate typically amounts to 95% of what the state normally pays the nursing facility for a non-hospice patient’s care. This payment is made to the hospice provider, who is responsible for passing the R&B payment through to the facility. Because Medicaid is administered by each state, the specific rules, reimbursement rates, and benefit availability vary significantly.
Navigating Eligibility and Care Setting Restrictions
Accessing Medicaid coverage for hospice room and board is subject to strict financial and setting-specific limitations. The applicant must qualify for Medicaid, which is a means-tested program requiring that the individual meet low-income and asset limits. These financial requirements often involve a “spend-down” process, where applicants must deplete their countable assets to a predetermined level, which in most states is exceptionally low.
The coverage for room and board is restricted to an institutional setting, most commonly a Medicaid-certified skilled nursing facility, where the patient is determined to require an institutional level of care. This criterion means the patient’s medical needs must be severe enough that, without the care provided in the facility, they would require hospitalization. For patients receiving care in a private home or an assisted living facility, the standard Medicaid benefit generally does not cover routine room and board expenses.
For patients who wish to remain in a non-institutional setting, coverage for room and board may sometimes be available through specific Home and Community-Based Services (HCBS) waivers. These waivers allow states to use Medicaid funds for services that help individuals remain in their communities. Some waivers can include payments for services that approximate room and board in non-skilled settings, like adult foster care. However, HCBS waivers are state-specific, often have limited enrollment capacity, and may maintain lengthy waitlists, making them a less reliable option than institutional coverage.
To receive the R&B benefit in a nursing facility, the patient must be approved for the Medicaid hospice benefit and maintain full Medicaid eligibility. This requires continuous monitoring of income and assets to ensure the patient remains below the state’s financial thresholds. Even small fluctuations in income or assets can jeopardize the continuation of the room and board coverage.