Does Hospice Room and Board Coverage Differ by State?

Partly. Medicare's rule is the same in every state: it does not pay room and board where a hospice patient lives, whether that is a house, an assisted living apartment or a nursing home. What differs by state is Medicaid. Federal law sets a floor: a state that covers hospice must pay at least 95% of what it would have paid the nursing home for a resident who qualifies for its nursing-home coverage. Each state then sets its own rates, its income and asset limits, and what the resident must contribute each month, so the real bill depends on the state and on whether the person has Medicaid.

What's the same everywhere

Because Medicare is a national program, these rules don't change from state to state:

• Hospice covers care for a terminal illness with a six-month-or-less prognosis if the disease runs its normal course.
• The benefit pays for the interdisciplinary team, terminal-diagnosis medications, and durable medical equipment.
• Room and board is not covered during Routine Home Care. The hospice benefit covers the facility stay only during a short General Inpatient (GIP) or inpatient respite stay that the hospice arranges.
• Inpatient respite is limited to 5 days in a row and is for patients cared for at home. Medicare's manual says it cannot be provided to someone who already lives in a facility such as a long-term care nursing home.
• The drug copay (up to $5 per prescription) and the respite coinsurance (5% of Medicare's payment for a respite day) apply nationwide. The dollar amount of that 5% can differ somewhat by area, because Medicare bases its hospice payments on where the care is given.

For the foundation, see hospice room and board: who pays.

Does every state's Medicaid pay nursing-home room and board on hospice?

If the state covers hospice and the person qualifies, yes. There is no separate room-and-board program for a state to opt into. Medicaid.gov lists nursing facility services as a mandatory benefit and hospice as an optional one. When a state covers hospice, the Social Security Act requires an added payment for room and board equal to at least 95% of the rate the state would have paid that facility for that person. In KFF's 2018 survey of state Medicaid benefits, no responding state said it did not cover hospice for adults, though five did not report, so confirm your own state's coverage.

The payment is not automatic. The person must qualify for nursing-home coverage under that state's Medicaid rules, and someone with both Medicare and Medicaid must elect hospice under both programs at once. Medicare's manual describes the usual path: the state pays the hospice, and the hospice pays the nursing home under a written agreement between them. See does Medicaid pay nursing-home room and board on hospice and who pays the room if a parent in a nursing home goes on hospice.

What actually differs by state

These examples come from federal and state Medicaid rules. They are not a 50-state list, because we could not find a current official one, and your state may differ.

If you remember one thing: the hospice benefit is national and fixed; the Medicaid rules that decide who gets help with the bed are set state by state.

If Medicaid pays only 95%, who pays the other 5%?

It should not fall on the family. The 95% is a floor on what the state pays the hospice, and the hospice and nursing home settle the amount under their agreement. Federal rules say a home may charge a resident who becomes eligible for Medicaid only what Medicaid allows, and Medicaid providers must accept the state's payment, plus any required cost sharing, as payment in full. If a 5% charge appears on a bill, ask the business office and the hospice social worker to explain it, and call your state's long-term care ombudsman if it isn't fixed.

How much will the resident still owe each month?

It depends on the resident's income, not on the 95%. Under federal rules, a state reduces what it pays by the resident's income left after set deductions: the personal needs allowance, support for a spouse or family at home, and medical costs no one else pays, such as health insurance premiums. For example, a single Texas resident with $1,500 a month in income and no other deductions would keep $75 and contribute $1,425 toward care. Texas, California and New York all keep this contribution in place after hospice is elected. For a spouse at home, see can a spouse keep the house.

Why two families can have very different bills

Take two people with the same diagnosis in the same kind of nursing home. With Medicare only, the resident pays the home's private rate in any state, because Medicare hospice does not cover that bed. With Medicaid, the state's rules decide. A single resident with $50,000 in countable savings would be over the Texas limit but under California's current limit, so the same person could be paying privately in one state and on Medicaid (Medi-Cal) in the other, if the state's other rules are met. None of this comes from the hospice benefit itself. That's why the most useful step is to confirm Medicaid status and your state's rules before care begins, rather than discovering the gap on the first invoice.

Other location-driven differences

A few other things vary by area, though these aren't room-and-board coverage rules:

• Facility room-and-board rates for nursing homes, assisted living, and residential hospice beds vary by region, and Medicare does not set them.
• Provider availability and the mix of nonprofit vs. for-profit hospices differ by area.
• Clinical guidelines for judging prognosis come from Medicare's regional contractors. One contractor's example is CGS's L34538, "Hospice Determining Terminal Status." Treat these as guidance a hospice physician applies in that region, not a national rule that decides who qualifies.

How to get your state's answer

• Call your state Medicaid agency. Medicaid.gov has a directory of every state's agency. Ask whether the state covers hospice, what the income and asset limits are for nursing-home coverage, and what the personal needs allowance is.
• Ask whether the resident is in a Medicaid managed-care plan. If so, ask the plan how room and board is paid on hospice.
• Ask the hospice social worker who will bill room and board, who collects the resident's monthly share, and whether the hospice has a written agreement with this nursing home.
• Ask the nursing home's business office whether it takes Medicaid and has a Medicaid bed, for its daily room-and-board rate in writing, and for its bed-hold policy.
• Ask about waivers if the setting is assisted living, and what they do and don't pay for.
• Get Medicare counseling from your State Health Insurance Assistance Program (SHIP). Call 1-800-MEDICARE for its contact details.

Frequently asked questions

Which states pay hospice room and board?

Medicare's hospice benefit does not pay it for someone living in a facility in any state. For Medicaid, any state that covers hospice must make the room-and-board payment for residents who qualify for its nursing-home coverage. We could not find a current official 50-state list, so confirm with your state Medicaid agency.

Is the Medicare hospice benefit different in my state?

No. Medicare is a federal program, so the covered services, the drug copay up to $5 per prescription, and the 5% respite coinsurance apply in every state. Medicaid's hospice benefit can differ: a CMS fact sheet says hospice benefits may not be the same in each state and that each state decides the life expectancy required to qualify.

Will Medicaid automatically pay the nursing-home bed when my parent goes on hospice?

Not automatically. If Medicaid already pays the bed, electing hospice does not end that. If it doesn't, your parent must first qualify for Medicaid nursing-home coverage, and CMS says someone found eligible may have to move to another home if no Medicaid bed is available or the home does not take Medicaid. See does Medicaid cover hospice.

Does hospice ever cover room and board anywhere?

Medicare's hospice benefit covers the bed only during General Inpatient and inpatient respite stays. Under Routine Home Care it does not cover room and board in any state.

We're moving to another state. Will coverage change?

Medicare's hospice rules won't, but moving out of your hospice's service area is a reason it can discharge you, so line up a hospice in the new area first. You can change hospices once in each election period; see can you switch or fire your hospice provider. Medicaid is run for each state's residents, so report the move and apply in the new state. It cannot make you wait out a residency period, but its limits and rates may differ.

Does assisted living get the same Medicaid room help as a nursing home?

No. The room-and-board payment is for nursing-facility residents, and federal rules bar Medicaid waivers from paying assisted-living room and board. A waiver may pay for some care services there, depending on the state. See does hospice pay for assisted living or memory care.

Can a state make adult children pay?

Federal rules bar a nursing home from requiring a third-party guarantee of payment, but state family-support laws can create other duties. Pennsylvania's, for example, makes a spouse, child or parent responsible for financially assisting an indigent relative, with exceptions. If a relative is billed personally, talk with an elder-law attorney or legal aid before paying.

Looking locally? Compare hospices near you and ask each one how it handles Medicaid room and board in your state. If hospice hasn't started, ask for a hospice evaluation, ask whether there is any charge, and ask the social worker to map the room-and-board picture for your specific state and setting.