Yes, Medicaid can pay for hospice care in a skilled nursing facility. The coverage works through two separate payment streams: the hospice agency receives reimbursement for medical and comfort care services, while Medicaid also covers room and board at the nursing facility. This dual payment structure means a Medicaid-eligible resident can receive end-of-life care without leaving the facility where they already live.
How Medicaid Hospice Coverage Works in a Nursing Facility
The hospice benefit under Medicaid is an optional service that states can choose to include in their Medicaid plans. Most states do offer it, but the specific details can vary. At the federal level, the benefit covers an array of comfort-focused services for people who are terminally ill: nursing care, physician services, medical social services, counseling for the patient and family, medical supplies and equipment, physical therapy, occupational therapy, and speech therapy.
When someone in a skilled nursing facility elects hospice, those hospice services layer on top of the everyday care the facility already provides. The hospice agency coordinates the plan of care and becomes responsible for managing the terminal illness and related symptoms. The nursing facility continues providing room, meals, personal care, and assistance with daily living.
Who Pays for What
This is where most confusion happens, and the answer depends on whether the person has Medicaid only or has both Medicare and Medicaid (known as “dual eligible”).
For Medicaid-only patients, Medicaid pays the hospice provider directly for all hospice-related medical services. Separately, Medicaid reimburses room and board at the nursing facility at a rate equal to 95% of the facility’s standard daily rate. That room and board payment goes to the hospice provider first, and the hospice is then responsible for passing it through to the nursing facility. Any income the patient is expected to contribute toward their own care (calculated through a standard post-eligibility process) is subtracted from that payment.
For people who have both Medicare and Medicaid, Medicare covers the hospice medical services while Medicaid picks up the room and board. Medicare explicitly does not cover room and board for hospice patients living in a nursing facility, so Medicaid fills that gap. This coordination between the two programs is one of the main reasons dual-eligible nursing home residents can receive hospice without facing out-of-pocket costs for their housing.
Eligibility Requirements
To qualify for the Medicaid hospice benefit, two things must happen. First, a physician must certify that the person is terminally ill. While the federal Medicaid rules don’t spell out an exact timeframe in the same language Medicare uses, the standard across programs is a prognosis of six months or less if the illness follows its expected course. Second, the person (or their representative) must formally elect the hospice benefit by filing a statement with a specific hospice provider.
Electing hospice comes with a significant trade-off. The person acknowledges that Medicaid will no longer cover treatments aimed at curing the terminal illness. Comfort care, symptom management, and pain relief continue. But aggressive treatments like chemotherapy intended to cure a cancer, for example, would no longer be covered. Medicaid can still cover treatment for conditions unrelated to the terminal diagnosis.
A hospice plan of care must be established before services begin. This plan outlines what the patient needs and how the hospice team will provide it.
Levels of Hospice Care
Not all hospice days look the same. Medicaid recognizes four levels of care, and the reimbursement rate changes depending on which level the patient needs on a given day.
- Routine home care is the standard, day-to-day level. In a nursing facility setting, this means the hospice team visits regularly to manage symptoms, adjust medications, and support the patient and staff. The nursing facility handles ongoing personal care.
- Continuous home care kicks in during a crisis period, such as uncontrolled pain or acute respiratory distress. It involves extended nursing care, sometimes for eight or more hours in a single day, to stabilize the situation.
- General inpatient care is short-term and used when pain or symptoms can’t be managed in the nursing facility. The patient may be transferred temporarily to a hospital or dedicated hospice inpatient unit for more intensive intervention.
- Inpatient respite care provides short-term relief for caregivers. This level applies more often to patients receiving hospice at home, but it can come into play depending on the care situation.
Most days in a nursing facility fall under routine home care. The higher levels exist for situations that demand more intensive support.
How the Nursing Facility and Hospice Work Together
The hospice agency and the nursing facility must have a formal agreement in place. This contract spells out each party’s responsibilities. The hospice retains authority over planning, coordinating, and prescribing all care related to the terminal illness. The nursing facility continues its role in providing the living environment, meals, and baseline personal care.
In practice, this means two care teams are involved. The nursing facility staff handles daily needs like bathing, dressing, and meals. The hospice team, which typically includes nurses, social workers, chaplains, and aides, visits to manage the terminal condition, provide emotional and spiritual support, and coordinate with the facility staff. The hospice can only authorize services that are expressly part of its written care plan.
What Hospice Does Not Cover
Once you elect hospice, Medicaid stops covering curative treatments for the terminal illness. If someone with end-stage heart failure elects hospice, for instance, Medicaid would no longer pay for a heart transplant evaluation or aggressive surgical interventions for that condition. It would still cover medications and therapies focused on keeping the person comfortable.
Treatments for unrelated conditions remain covered. A hospice patient who develops a urinary tract infection unrelated to their terminal diagnosis can still receive antibiotics through Medicaid. The distinction between “related” and “unrelated” conditions sometimes creates gray areas, and the hospice team typically helps navigate those decisions.
It’s also worth knowing that the hospice election is not permanent. If a patient’s condition improves or they change their mind, they can revoke hospice and return to full Medicaid coverage at any time.
State Variations to Be Aware Of
Because the hospice benefit is optional under Medicaid, each state decides whether to offer it and sets its own reimbursement rates within federal guidelines. The 95% room and board rate is a federal standard, but states may have different daily rates for skilled nursing facilities, which directly affects how much the hospice and facility receive. Some states also have specific requirements around which hospice providers can serve nursing facility residents, or additional paperwork for the election process.
If you’re trying to arrange hospice for a family member in a nursing facility, your best starting point is the facility’s social worker or case manager. They can confirm which hospice agencies have contracts with that facility and help coordinate the enrollment process with your state’s Medicaid program.