Does Medicaid Cover Hospice Care?

The emotional experience of caring for a terminally ill loved one is filled with a mix of complex feelings. The decision to move a loved one into hospice care can bring a sense of relief but also guilt, sadness, and even a feeling of failure. Not to mention, the financial costs add to your anxiety. Medicaid can help ease some of your financial burden, allowing you to concentrate on your loved one and yourself.

Understanding the system: Medicaid and hospice

The healthcare system can be complex to navigate, especially regarding end-of-life care. Medicaid offers health insurance coverage for physician services to low-income individuals and family caregivers.

Is your care recipient eligible? It depends on the state. Generally, Medicaid recipients demonstrate financial need, have legal residency or citizenship, and may qualify under special circumstances.

What is hospice?

Your loved one's doctor may recommend hospice care. But what exactly is hospice? Hospice care is an optional state plan service that prioritizes comfort and pain management for terminally ill patients. It provides support for patients with terminal conditions, focusing on maintaining pain and comfort rather than addressing the illness itself.

The services may include nursing, medical social services, physician services, counseling services for the terminally ill individual and their family members or caregivers at home, short-term inpatient care, medical supplies, home health aide and homemaker services, physical or occupational therapy, and speech-language pathology. 

What are the four levels of hospice care?

The specific level of hospice care your loved one needs depends on their condition. The most common levels are:

1. Routine Home Care (RHC): This level of care is the most frequent option, providing long-term care in the patient's home environment. Many more family caregivers prefer home management. The patient stays in a familiar environment surrounded by loved ones, even pets.
2. General Inpatient Care (GIC): Sometimes, pain cannot be managed at home and requires care in a hospital or skilled nursing facility. This level of care is short-term and intended for pain control or symptom management.
3. Continuous Home Care (CHC): This level of care is provided during a crisis and primarily consists of nursing care. Similar to general inpatient care, it is offered within the patient's home to manage severe pain or symptoms.
4. Inpatient Respite Care (IRC): This level of care temporarily relieves family members or others caring for the individual. Respite can be provided in a nursing home, hospice inpatient facility, or hospital.

Palliative vs. hospice care

While both palliative and hospice care share core principles like pain management and emotional support, there is a difference:

• Palliative care focuses on maintaining the highest quality of life for people with serious, complex, and often terminal illnesses while still managing treatment and other needs.
• Hospice care focuses on supporting patients in the period closest to death, typically defined as a remaining life expectancy of six months or less.

Does Medicaid cover hospice?

Both Medicare and Medicaid offer hospice coverage but differ in services covered and eligibility requirements:

• Routine home care: covered by both Medicare and Medicaid.
• General inpatient care: covered by both Medicare and Medicaid.
• Inpatient respite care: covered up to five days by Medicare; Medicaid coverage may vary by state.
• Continuous home care: covered by Medicare; Medicaid coverage may vary by state.
• Beneficiary costs: typically no out-of-pocket costs under Medicare; Medicaid may have some cost-sharing requirements.
• Access to providers: Access to all Medicare-certified providers; Access to providers may vary by state under Medicaid.

How to apply for Medicaid hospice services

To qualify for the hospice benefit under Medicaid, your loved one needs to be enrolled in Medicaid, have a terminal illness documented by their physician, and choose comfort care instead of curative treatments.

1. Find a hospice provider: To get started, find a hospice provider. Contact a state hospice organization for recommendations. The beneficiary will need to sign a form with the hospice agency stating that they understand that other Medicaid treatments for their terminal condition will be stopped. (Note: you can change your mind at any time and go back to receiving the Medicaid services that were stopped when they chose hospice care.)
2. Get medical documentation: The hospice provider will need to obtain a physician certification that the care recipient is terminally ill, and hospice services are necessary to manage the terminal illness and related conditions.
3. Establish a plan of care: Work closely with the hospice team to develop a personalized hospice plan, which is required before services are provided. This plan should outline care, pain control, visit frequency, hospice physician services, and equipment or supplies.

A note from Givers

Your loved one deserves quality care, meaning that all their needs are met and provided by trained staff who respect your loved one's and family's choices. If you feel your loved one is not getting the hospice care they deserve, contact the hospice provider or call Adult Protective Services in your state.