Medicaid Considerations for Hospice Care at Home

Infographic Embed Code

Each year, Medicaid provisions help millions of Americans receive the health care they need. Its programs are numerous and can be applied to a large array of conditions. However, one of Medicaid’s particularly useful programs has been underutilized over the past years. This program provides hospice care at home for individuals who qualify for the aid and could provide a hugely different quality of life for terminally ill patients.

Health professional with tablet

What is Covered by the Medicaid Hospice Benefit?

Medicaid includes a program entitled the “Hospice benefit.” The hospice benefit provides a variety of services to those who have been declared terminally ill. The program varies by state. States can decide on their own definitions of “terminal” illness. Once a patient qualifies for the hospice benefit, Medicaid will provide a number of services for the individual including:

  • Nursing care
  • Medical social services or social worker services
  • Physician services
  • Counseling services (for both the patient and their family members/caretakers)
  • Short-term inpatient care for pain management, symptom control, and respite care
  • Medical appliances and supplies
  • Home health aide and homemaker services
  • Drugs for symptom control and pain relief
  • Dietary counseling
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology

These types of services are funded based on the level of Medicaid coverage granted, and may also vary from state by state.

Who Qualifies for Home Health Coverage

The Medicaid hospice benefit was created to help patients who have become terminally ill. This comprises those who will die from their condition within a foreseeable amount of time. In order to receive Medicaid hospice care medical coverage, the patient must be deemed “terminally ill” by a physician. Terminal illness implies a limited life expectancy, but the expected life duration can vary by state. For instance, Kentucky and Texas adopt the Medicare definition of terminal illness that stipulates a life expectancy equal to or less than six months if the condition runs its normal course. However, states retain the prerogative to adjust this amount. For example, New York allows a terminal illness to constitute conditions that may take up to 12 months to reach termination. In order to qualify as a terminally ill patient, an individual must have documentation in their medical record from a certified physician verifying their prognosis.

Another stipulation for being covered by the Medicaid hospice benefit is having a clear condition diagnosis filed with one’s records. According to the U.S. Department of Health and Human Services’ Center for Medicare and Medicaid Services (CMS), “The rules clarify that nonspecific symptom diagnoses, such as adult failure to thrive, dementia, and debility, may no longer be considered the principal diagnosis for determining eligibility under the Medicare hospice program. Nonspecific symptom diagnoses listed as principal diagnoses will be identified as questionable encounters and will be returned to the provider for a more definitive principal diagnosis.” This rule may vary by state.

How the Medicaid Hospice Benefit Works

The Medicaid hospice benefit requires that an application called an “election of hospice benefits” form be submitted for consideration.

  • In order to apply for Medicaid hospice benefit, an individual must select a hospice provider and then produce for that hospice provider a physician certification of terminal illness.
  • The hospice provider must then create a care plan to be submitted with the application.
  • The individual must acknowledge in their form submission that they understand hospice care forfeits curative Medicaid services (medical benefits that cover services meant to cure their condition) in favor of services that are palliative in nature. However, the individual can at any time opt out of hospice benefits and resume previous medical coverage. NOTE: Patients under 21 are afforded the opportunity to receive both curative and palliative (hospice) care coverage under the Affordable Care Act as of March 2010. They do not have to make this acknowledgement.
  • If clarifications or adjustments must be made to the application, the process will continue and individuals will need to correct their application before submitting for re-evaluation.
  • Once a Medicaid hospice benefit has been approved for an individual, payments for their care are made directly to their hospice provider for any services received.

When Medicaid Home Health Options Should be Considered

Any patient who has been deemed terminally ill by a qualified physician could be eligible for hospice benefits provided by Medicaid. If a patient has received a terminal diagnosis and his or her medical care providers have advised that palliative rather than curative care would be the best option for treatment, the Medicaid hospice benefit could provide a substantial boon by covering or contributing towards the cost of palliative care for that patient. Except in the case of patients under age 21, the Medicaid hospice benefit should only be considered if further curative treatment options (attempts to cure the illness or condition) will no longer be considered. In cases of patients facing terminal illness, the Medicaid hospice benefit could provide substantial financial assistance towards covering the best possible care during their last months. Hospice care can provide a comfortable and secure option and Medicaid can help make it possible for those facing terminal illnesses, providing assistance not only for the patient but for their families and caretakers as well.

Legal professionals who are consulted or hired to work with cases involving Medicaid-provided hospice care should maintain a thorough understanding of the current legal statutes in place that govern Medicaid provisions. Issues including who owes what, to whom, and how much, can quickly become complicated and often require legal counsel.

Learn More
To learn to speak the language of health law and distinguish your role as a leader with specialized health care compliance expertise, look to pursue a Master’s in Health Law and Policy from Hofstra Law.

Recommended Readings
The Rise of Home Health Care in 2017
The Shift from Personalized Health Care to Precision Medicine
Medicare Through a Health Law Perspective

Centers for Medicare & Medicaid Services
U.S. News & World Report
Hinds Hospice