Hospice at Home vs. Hospice in a Facility: How Florida Medicaid Pays for Each

Constance's Decision

Constance is 90 and has lived in an Ocala nursing facility for about a year, with Medicaid already covering her stay there as a long-term care resident. Her heart failure has advanced, and her physician has certified her as appropriate for hospice. Her daughter has offered to bring her home for whatever time she has left. Constance is a composite I use to illustrate a question that comes up often in my practice, not an actual client, but her situation reflects what hundreds of Florida families work through every year.

The good news for a family in this position is that hospice is covered either way. What changes between home and facility is not whether Medicaid pays, but what it pays for, and how the household's finances are affected.

What the Hospice Benefit Actually Covers

Hospice in Florida is built on a federal framework. Under 42 CFR 418.22, a patient qualifies for hospice once a physician certifies a terminal prognosis, and under 42 CFR 418.24 the patient (or their representative) formally elects the hospice benefit in place of curative treatment for the terminal condition. This applies the same way whether the patient is on Medicare, Medicaid, or both, and it is not limited by age.

Once elected, the hospice benefit typically includes:

• Visits from hospice nurses, aides, social workers, and chaplains
• Medications related to the terminal diagnosis
• Medical equipment and supplies tied to comfort care
• Physician oversight of the hospice plan of care
• Bereavement support for the family after death

What hospice does not cover is treatment aimed at curing the terminal illness, or routine room and board for a patient living at home (because there is no facility billing for a home setting in the first place). This is where the two settings start to look different.

Hospice at Home: What Medicaid Pays

If Constance goes home with her daughter, the hospice agency bills for its visits and services the same way it would anywhere. There is no room and board to reimburse because she is not living in a licensed facility. Her daughter absorbs the household costs of having her there: meals, utilities, a comfortable place to rest, any home modifications.

If Constance had been receiving her care through a Medicaid home and community-based services waiver rather than a nursing facility, that arrangement would generally continue to coordinate alongside hospice, with hospice covering the terminal-illness-related care and the waiver program covering other approved supports. The exact coordination depends on her specific program and should be confirmed with her hospice agency and caseworker.

For many families, the emotional value of bringing a parent home for their final weeks or months outweighs the practical load. But it is worth being honest about what that load involves before committing to it.

Hospice in the Nursing Facility: Why Florida Medicaid Pays More Than People Expect

This is the part of the hospice benefit that surprises a lot of families, including ones who have already been navigating Medicaid for a parent in a facility for months or years. Medicare's hospice benefit, on its own, does not pay a nursing facility's room and board. Florida Medicaid does.

In plain terms: electing hospice while in the nursing facility does not take away the Medicaid coverage that has been paying for her bed, meals, and custodial care. It adds a hospice layer on top of it. There is one technical shift worth knowing about: once she elects hospice, she is reclassified for Medicaid billing purposes as a hospice patient rather than a standard nursing facility patient, even though she continues living in the same bed with the same care team involved. Room and board reimbursement does not extend to the day of discharge or the day of death itself, though hospice clinical services on that day are still covered.

Does Electing Hospice Change Her Medicaid Eligibility or Patient Responsibility?

No. The financial rules that got Constance qualified for nursing facility Medicaid, her countable income, her countable assets, any community spouse protections if applicable, do not change because she elects hospice. Hospice is a service election layered onto existing Medicaid eligibility, not a separate eligibility category with its own income and asset tests.

Her patient responsibility (sometimes called the share of cost) also continues to work the same way it did before hospice: she contributes her countable income toward her cost of care, minus her personal needs allowance and any deducted amounts such as a health insurance premium, and Medicaid and the facility arrangement cover the rest. The personal needs allowance is the small monthly amount a Medicaid nursing facility resident is permitted to keep for personal items like clothing, toiletries, or a haircut. Facilities and hospice providers coordinate billing between themselves; the family generally does not see a change in what they are asked to contribute simply because hospice was elected.

If Constance's condition stabilizes or she chooses to pursue treatment again, she has the right to revoke hospice at any time. Doing so returns her to standard nursing facility Medicaid billing, and she can re-elect hospice again later if she becomes eligible again.

The Decision, and What Comes After

For Constance's daughter, the Medicaid financing of each option was never really the deciding factor, since both home and facility care are covered. The real questions were about caregiving: whether her home could physically accommodate a hospital bed and equipment, whether she could be present enough during the day, and whether Constance herself had a strong preference. Families in this position often find it useful to talk through both settings with the hospice intake team and with a case manager connected through the Department of Elder Affairs' CARES program or a local Aging and Disability Resource Center, since those professionals see this transition constantly and can describe what day-to-day support actually looks like in each setting.

One thing that does not change regardless of where Constance receives hospice care: Florida Medicaid's estate recovery program may still seek reimbursement from her estate after her death for Medicaid long-term care benefits paid on her behalf, consistent with federal and Florida law. That is a separate process from hospice billing itself, and I cover it in detail in a dedicated article, but families should expect a notice from the state's estate recovery contractor sometime after death and should know in advance that receiving a letter is a normal, expected part of closing out a Medicaid long-term care case, not a sign that something went wrong.

This article is for general informational purposes only and does not constitute legal advice, nor does reading it create an attorney-client relationship. Florida estate, elder, probate, and real estate law are fact-specific and change over time. Consult a licensed Florida attorney about your individual circumstances. Arthur Simpson, Esq. is licensed to practice law in the State of Florida. Attorney advertising.