Georgia Medicaid Hospice Coverage 2026

Georgia Medicaid hospice coverage is an optional state plan benefit for members with a terminal prognosis of six months or less. A nursing facility resident can elect hospice without leaving the facility: federal law requires Medicaid to pay the hospice an extra room and board amount equal to at least 95 percent of the facility's Medicaid rate, which the hospice passes through to the facility. A Medicaid child under 21 can receive hospice and curative treatment for the same terminal illness at the same time. This guide explains who qualifies, what the benefit pays, the four levels of care, the nursing facility pass-through, pediatric concurrent care, dual-eligible coordination, and how to elect.

In This Guide

• Does Georgia Medicaid cover hospice?
• Who qualifies for Georgia Medicaid hospice coverage?
• What are the four levels of hospice care?
• What does Georgia Medicaid hospice coverage include?
• How do I elect or revoke hospice?
• Can I keep my nursing facility room on hospice?
• Can a child get hospice and keep treatment?
• What does Medicaid pay if I also have Medicare?
• How does the hospice cap affect me?
• Worked examples
• Frequently Asked Questions
• Learn More

Does Georgia Medicaid cover hospice?

Yes. Hospice is an optional Medicaid state plan benefit, and Georgia has elected it. The benefit is comfort-focused end-of-life care for a member with a terminal illness who chooses comfort care instead of curative treatment for that illness. It covers the four federally defined levels of care set out in the 42 CFR Part 418 hospice Conditions of Participation, the interdisciplinary team, all hospice-related medications and equipment, and family bereavement support. The Georgia Department of Community Health (DCH) administers Medicaid policy; the Georgia Division of Family and Children Services (DFCS) handles eligibility.5

Medicaid hospice mirrors the Medicare hospice benefit payment structure. For dual-eligible members (those with both Medicare and Medicaid), Medicare Part A is the primary payer; Georgia Medicaid wraps around it, as explained below.6

Who qualifies for Georgia Medicaid hospice coverage?

Three requirements must be met at the same time.

1. Medicaid enrollment. The member must be enrolled in Georgia Medicaid. Any eligibility category qualifies: aged, blind, and disabled (ABD); institutional long-term care; Home and Community-Based Services (HCBS) waiver participants; dual eligibles; Pathways to Coverage adults; pregnant women; and children. Standard Medicaid eligibility rules continue throughout the hospice stay.

2. Terminal prognosis of six months or less. Two physicians (the hospice medical director and the patient's attending physician) must certify that the patient has a life expectancy of six months or less if the disease runs its normal course. Common qualifying diagnoses include cancer, advanced dementia, end-stage heart failure, Stage 4 chronic obstructive pulmonary disease (COPD), neurodegenerative disease such as amyotrophic lateral sclerosis (ALS), end-stage renal or liver disease, and debility or failure to thrive in frail elderly patients.1

3. Voluntary election. The patient or their legal representative voluntarily signs a hospice election statement under 42 CFR 418.24. The election waives curative treatment for the terminal illness and related conditions, but not for unrelated conditions. The patient may revoke at any time without penalty.

How long do hospice benefit periods last?

Hospice coverage is divided into benefit periods under 42 CFR 418.21(a). A physician must recertify the terminal prognosis at the start of each one. Beginning with the third benefit period and every period after, a hospice physician or nurse practitioner must have a face-to-face encounter with the patient before recertification. There is no overall time limit as long as recertification continues.1

What are the four levels of hospice care?

The benefit pays at one of four federally defined levels under 42 CFR 418.302(b). A patient moves between levels as their clinical needs change.5

The rates above are national base figures effective October 1, 2025 through September 30, 2026, reflecting the 2.6 percent FY2026 payment update; the amount actually paid in Georgia is adjusted by the local hospice wage index.4

Continuous Home Care (CHC). For an acute symptom crisis at home, CHC delivers extended nursing presence to avoid an inpatient admission. A minimum of 8 hours of care must be furnished on a given day to qualify for the CHC rate, and that care must be predominantly nursing care. CHC reverts to routine home care once the crisis resolves.5

Inpatient Respite Care (IRC). For caregiver relief, the patient is admitted briefly to a certified facility. IRC may not be provided for more than 5 consecutive days at a time; the sixth and any later day is paid at the routine home care rate. Respite is one of the most underused levels, and many families wait until they collapse before requesting it.5

What does Georgia Medicaid hospice coverage include?

Under 42 CFR 418.64, the hospice provides a core set of services through an interdisciplinary team, all covered by the per diem:

• Physician services from the hospice medical director plus attending physician oversight.
• Nursing services, including a registered nurse (RN) case manager and 24-hour on-call nursing.
• Medical social services from a licensed social worker.
• Counseling, including spiritual care from a chaplain, dietary counseling, and bereavement counseling for the family.
• Home health aide and homemaker services for personal care and limited household tasks.
• Physical, occupational, and speech-language therapy as needed for comfort and function.
• Volunteer services, required under 42 CFR 418.78.
• Hospice-related medications, DME, and supplies (hospital beds, wheelchairs, oxygen, wound and incontinence supplies). These come from the hospice, not the retail Medicaid pharmacy or DME benefit.

Bereavement support continues after the death. Under 42 CFR 418.64(d)(1)(ii), the hospice must make bereavement services available to the family for up to 1 year following the patient's death.7

What does hospice not cover?

Hospice does not cover curative treatment for the terminal illness (with the concurrent-care exception for children under 21, below) or treatment for that illness's related conditions. Treatment for unrelated conditions continues under regular Medicaid. Hospice does not cover room and board in an assisted living facility or personal care home; the Medicaid room and board pass-through applies only to nursing facilities that meet Medicaid certification.2

How do I elect or revoke hospice?

The election statement under 42 CFR 418.24 names the chosen hospice, acknowledges that hospice care is palliative, states that the election waives curative treatment for the terminal illness and related conditions, sets an effective date, and carries the patient's or representative's signature.

You may revoke the election in writing at any time under 42 CFR 418.28. On revocation, you return to regular Medicaid benefits immediately, with no penalty, and you may re-elect hospice later if you still qualify, in a new benefit period. There is no limit on how many times you may elect, revoke, and re-elect.1 You may also change hospice providers once per benefit period under 42 CFR 418.30 without it counting as a revocation. A hospice may discharge you only in limited circumstances under 42 CFR 418.26 (you move out of its service area, it can no longer meet your needs, you no longer meet the terminal-prognosis test, or, rarely, for documented safety reasons), and a for-cause discharge is subject to appeal.

Can I keep my nursing facility room on hospice?

Yes, and this is the most misunderstood part of the benefit. A nursing facility resident can elect hospice and stay in the facility. Under 42 USC 1396a(a)(13)(B), Medicaid pays the hospice an additional room and board amount equal to at least 95 percent of the rate the state would otherwise have paid the facility, and the hospice pays that amount through to the facility.2

The payment flow works like this:

1. Medicaid pays the hospice the hospice per diem (most days at the routine home care rate).4
2. Medicaid also pays the hospice the room and board amount, at least 95 percent of the facility's Medicaid rate.2
3. The hospice pays the facility for room, board, and general nursing facility services (custodial care, dietary, housekeeping, activities).

Because the facility keeps at least 95 percent of its usual Medicaid revenue, it has no financial incentive to discharge a hospice patient. This setup is the most common Medicaid hospice placement for end-stage dementia, advanced heart failure, and other slowly progressive conditions.2

What does the resident still pay?

A nursing facility resident on hospice still owes the same patient liability to the facility each month. Patient liability is the resident's income (typically Social Security) minus the Personal Needs Allowance, which is $70 per month in Georgia, minus the Medicare Part B premium and other allowed deductions. So three streams cover the facility's cost: the resident's patient liability to the facility, the Medicaid hospice per diem, and the Medicaid room and board pass-through through the hospice.8

Can a child get hospice and keep treatment?

Yes. For adults, electing hospice waives curative treatment for the terminal illness. For children, Section 2302 of the Affordable Care Act, codified at 42 USC 1396d(o)(1)(C), removed that trade-off: a Medicaid child under 21 who elects hospice does not waive the right to also receive, and have Medicaid pay for, curative treatment of the terminal condition. The child can receive both at the same time.3

In practice, a child with terminal cancer can continue chemotherapy, surgery, radiation, or inpatient treatment while also receiving the full hospice team, symptom management, family support, and bereavement services. The family does not have to choose between fighting the illness and comfort care. Most pediatric oncology programs in Georgia, including the Children's Healthcare of Atlanta Aflac Cancer and Blood Disorders Center, coordinate hospice with continued treatment.3

On top of concurrent care, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requires Georgia Medicaid to cover all medically necessary services for children under 21. For a child on hospice, that can mean additional medically necessary services beyond the standard hospice array, such as pediatric private duty nursing, extra DME, or behavioral health support.9

What does Medicaid pay if I also have Medicare?

For a dual-eligible member, Medicare Part A is the primary payer for hospice. Medicare covers all four levels of care, the interdisciplinary team, and hospice-related medications and equipment, with minimal cost-sharing (no more than $5 for each outpatient prescription drug for pain and symptom management, and 5 percent of the Medicare-approved amount for inpatient respite care). Adult Medicare beneficiaries do not get concurrent care; the Section 2302 exception applies only to Medicaid children under 21.6

A common misconception is that Medicaid stops paying anything once a dual eligible elects Medicare hospice. That is wrong. Georgia Medicaid continues to wrap around Medicare in the following ways.

The nursing facility pass-through and the unrelated-condition coverage are the largest continued Medicaid responsibilities for a dual eligible on hospice.2,8

How does the hospice cap affect me?

To limit inappropriate long-stay utilization, both Medicare and Medicaid apply an annual aggregate cap on payments to each hospice, under 42 USC 1395f(i)(2) and 42 CFR 418.309. The cap equals the per-beneficiary cap amount, which is $35,361.44 for the FY2026 cap year, multiplied by the number of beneficiaries the hospice served that year. A hospice whose total payments exceed its cap must repay the excess.4

For members, the practical effect is that some hospices manage their mix of patients to avoid exceeding the cap. A member whose prognosis could run beyond six months should be candid about the clinical picture; the right hospice will admit and continue care as long as recertification supports it.

Worked examples

Eleanor, 84, end-stage Alzheimer's in a nursing facility

Eleanor has end-stage Alzheimer's at Functional Assessment Staging Tool (FAST) stage 7 and lives in a Medicaid nursing facility. The hospice medical director and her physician certify a terminal prognosis. Her daughter signs the election as her power of attorney, and Eleanor stays in the facility. The hospice provides RN case management, home health aide visits, chaplain and social work visits, all medications, and equipment. Medicaid pays the hospice the routine home care per diem plus the room and board pass-through (at least 95 percent of the facility's Medicaid rate), and the hospice pays the facility. Eleanor continues to pay her monthly patient liability (her income minus the $70 Personal Needs Allowance and her Medicare Part B premium). Beyond that patient liability, her family pays $0, and the hospice makes bereavement services available to the family for up to a year after she dies.2,8,7

Tasha, 8, glioblastoma with concurrent care

Tasha has recurrent glioblastoma. Two physicians certify a terminal prognosis, and her family elects pediatric hospice. Under Section 2302 of the Affordable Care Act, she continues chemotherapy infusions and inpatient treatment at the Children's Healthcare of Atlanta Aflac Cancer and Blood Disorders Center while also receiving the full pediatric hospice team, symptom management, and family support. The curative treatment is billed to Medicaid outside the hospice benefit. Because EPSDT bars cost-sharing for children, the family pays $0.3,9

Wallace, 88, dementia with an unrelated hip fracture

Wallace lives in a Medicaid nursing facility, has advanced dementia, and elected hospice eight months ago. He falls and fractures a hip. Because the hip fracture is unrelated to dementia (his terminal illness), the hospital admission, surgical repair, and recovery are covered by regular Georgia Medicaid, not by the hospice benefit. The hospice continues to manage his dementia symptoms throughout, and adds post-surgical pain management because pain control is comfort care. Medicaid keeps paying the hospice the per diem plus the room and board pass-through to the facility. Beyond his ongoing patient liability, the family pays $0.2

What to do next

If you or a family member may qualify for hospice, the first step is usually a referral from the treating physician or the nursing facility social worker to a Medicare- and Medicaid-certified hospice, which arranges the physician certification and the election. To confirm Medicaid eligibility, ask about a coverage problem, or request a fair hearing on a Medicaid decision, use the contacts below. To keep benefits during an appeal of a closure, request the fair hearing within 12 days of the notice.10

Learn More

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.