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 an extra room and board amount equal to at least 95 percent of the facility's Medicaid rate, and CMS makes the hospice responsible for passing that payment 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. The full-benefit eligibility categories qualify: 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. The hospice must obtain a written physician certification that the patient has a life expectancy of six months or less if the disease runs its normal course, and a fresh written certification for each later election period. Under Medicare's rule, the certification comes from the hospice doctor and the patient's own regular doctor, if the patient has one.6 Common qualifying diagnoses include cancer, advanced dementia, end-stage heart failure, advanced chronic obstructive pulmonary disease (COPD), amyotrophic lateral sclerosis (ALS), and end-stage renal or liver disease.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.

How long do hospice benefit periods last?

Hospice coverage is divided into election periods. The 90/90/60 schedule below is the Medicare schedule set by 42 CFR 418.21(a), and it is the pattern hospices work from; under 42 USC 1396d(o)(2) each state sets its own Medicaid election periods, which need not be the same periods as Medicare's. Whatever the period length, the hospice must obtain a written physician certification of the terminal prognosis for each one, and for a dual-eligible member Medicare's schedule is what governs the certifications. Beginning with the third Medicare benefit period and every period after, a hospice physician or nurse practitioner must have a face-to-face encounter with the patient no more than 30 calendar days before the 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

Those rates come from CMS's annual Medicaid hospice rate memorandum and run from October 1, 2025 through September 30, 2026, reflecting the 2.6 percent FY2026 hospice payment update. They are the rates for providers that submitted the required quality data, they are federal minimums (Georgia may pay more), and the amount actually paid is adjusted for the local hospice wage index.4

Medicaid's schedule is calculated from the Medicare hospice rates but is not identical to them. For a dual eligible whose hospice care is billed to Medicare, the FY2026 Medicare inpatient respite rate is $532.48 per day, roughly $28 below the Medicaid minimum, while general inpatient care is $1,199.86 per day under both.4

Continuous Home Care (CHC). 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.5

What does Georgia Medicaid hospice coverage include?

Under 42 CFR 418.202, the following are covered hospice services, delivered by an interdisciplinary team and all paid for by the per diem (the first four are the core services the hospice must provide itself, under 42 CFR 418.64):

• 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.
• Medications for pain and symptom control related to the terminal illness, plus DME and medical 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. Revoking ends hospice coverage for the remainder of that election period, so you give up the days left in it, and you return to regular Medicaid benefits, including curative treatment, immediately. You may elect hospice again for any later election period you are eligible to receive.8 Because the 60-day periods after the first two are unlimited, re-electing later is normally possible.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 must pay an additional amount on top of the hospice per diem, to take into account the room and board the facility furnishes, equal to at least 95 percent of the rate the state would otherwise have paid that facility for the resident. CMS describes how that works in practice: the room and board per diem is paid to the hospice provider at 95 percent of the nursing facility rate, less any post-eligibility treatment of income (the resident's own contribution toward their care), and the hospice is responsible for passing the room and board payment 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, reduced by the resident's patient liability.2
3. The hospice pays the facility for room, board, and general nursing facility services (custodial care, dietary, housekeeping, activities).

Between that pass-through and the resident's own patient liability, the facility still receives at least 95 percent of the rate Medicaid was paying before the election, so it has little financial incentive to discharge a hospice patient. This is a common Medicaid hospice arrangement for end-stage dementia and other slowly progressive conditions.2

What does the resident still pay?

A nursing facility resident on hospice still owes the same patient liability 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.9 That liability is the post-eligibility treatment of income CMS subtracts from the room and board pass-through, so it is not an extra charge stacked on top: Medicaid pays the hospice 95 percent of the facility's rate less what the resident already contributes, and the resident's share plus the pass-through together cover the facility.2

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 receiving the full hospice team and family support. The family does not have to choose between fighting the illness and comfort care.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.10

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 once a dual eligible elects Medicare hospice. It does not. Georgia Medicaid wraps around Medicare in these ways.

The nursing facility pass-through and the unrelated-condition coverage are the largest continued Medicaid responsibilities for a dual eligible on hospice.2,9

How does the hospice cap affect me?

To limit inappropriate long-stay utilization, Medicare applies an annual aggregate cap on what it pays 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 Medicare beneficiaries in that hospice's program that year; payments above the cap are overpayments the hospice must refund.11

The aggregate cap is a Medicare limit, not a Medicaid one. It reaches Georgia Medicaid members only indirectly, because Medicaid pays for hospice care using the same methodology as Medicare Part A and in amounts no lower (42 USC 1396a(a)(13)(B)), so the same payment structure a hospice manages against on the Medicare side shapes what it is paid on the Medicaid side.11

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, less her patient liability), 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, because Georgia Medicaid charges no copays to nursing facility residents or to members in hospice care,12 and the hospice makes bereavement services available to the family for up to a year after she dies.2,9,7

Tasha, 8, glioblastoma with concurrent care

Tasha has recurrent glioblastoma. Her hospice doctor and her treating oncologist 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 her children's hospital 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 Georgia Medicaid charges no copays to members under 21, the family pays $0.12,3,10

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, 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 certification and the election. To confirm Medicaid eligibility, ask about a coverage problem, or request a fair hearing, use the contacts below. If your coverage is being closed and you want it to keep running while you appeal, DFCS says the request to continue receiving benefits must be made within 12 days of the closure notice, and that you may have to repay those benefits if the hearing does not go your way. That 12-day window covers continued benefits, not the hearing request itself, so use the appeal deadline printed on your notice.13

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.