Six states recently participated in NASHP’s two-year State Policy Institute to Improve Care for People with Serious Illness (the Institute). Colorado, Maine, Maryland, Ohio, Texas, and Washington applied for and were accepted to the Institute because the state leaders on each team were committed to exploring, developing, and/or strengthening policies and strategies to improve access to palliative care for Medicaid beneficiaries.
Through the Institute, the states engaged in peer-to-peer learning and received technical support from NASHP and subject matter experts on serious illness and palliative care policy.
What is Palliative Care?
Palliative care is team-based medical care for people living with a serious illness. The care centers on providing relief from the symptoms and stress of the illness, at any stage of the illness, and can be provided along with curative treatment. Services such as pain management, care planning, and care management can help people maintain quality of life and avoid unnecessary and often unwanted treatment.
Reimbursement is often cited as the biggest barrier to the availability of palliative care. Not all payers will cover palliative care services, and community-based palliative care is delivered by an interdisciplinary team. While members of a palliative care team, such as physicians, can usually bill payers for their services, others often cannot. Further, palliative care services such as care coordination are often provided outside of a face-to-face visit. Given these complexities, states chose to focus on Medicaid reimbursement for palliative care in NASHP’s Institute.
Cutting-Edge State Actuarial Simulations
NASHP’s Institute was a unique opportunity for states to work with experienced actuaries and insurance benefit design specialists to explore and develop a Medicaid palliative care benefit.
Specifically, the six participating states received guidance on policy mechanisms to cover palliative care services in the community and completed cost analysis on palliative care services for Medicaid beneficiaries. While all the states balanced the same forces and demands, such as promoting the health and well-being of their populations and the responsible use of public dollars, each state modeled a benefit that was responsive to its particular needs and circumstances. Working with NASHP and other expert consultants, each state determined the right mix of benefits to cover, providers to include, and beneficiaries to target.
CBIZ Optumas and TFA Analytics then designed a cost calculator for each state to help with different scenarios. Through analysis of the state’s Medicaid beneficiaries and potential impact of comprehensive palliative care services, the cost calculator simulated the costs and return-on-investment of a Medicaid palliative care benefit. The assumptions of the cost calculator were based on previous actuarial analysis commissioned by NASHP and completed by CBIZ Optumas.
This analysis found that a comprehensive palliative care Medicaid benefit is expected to be, at minimum, overall cost neutral to the state. In addition, effective administration of a Medicaid palliative care benefit for the highest service utilizers can result in avoided adverse events such as emergency visits or inpatient stays. This could produce significant cost savings and potential return on investment ranging between $0.80 and $2.60 for every $1 spent on palliative care.
State Progress
While the participating states are in different stages of designing and implementing Medicaid palliative care coverage, these states made significant progress during the NASHP Institute:
Ohio added community-based palliative care services as required supplemental services in the Next Generation MyCare Ohio program. As per the provider agreement, Medicaid managed care plans for dually eligible beneficiaries who participate in MyCare Ohio are now required to cover palliative care services.
Maine is legislatively mandated to provide reimbursement under the MaineCare (Medicaid) program for palliative care. As the state develops its service model and reimbursement methodology, it has contracted with the Maine Hospice Council to carry out a statewide palliative care education campaign. The campaign aims to increase awareness of what palliative care is and how it can benefit patients and families in advance of the state expanding access to palliative care.
The Texas Palliative Care Interdisciplinary Advisory Council, which advises the Texas Health and Human Services Commission (HHSC) and the state legislature, submitted its Recommendations to the 89th Texas Legislature. Based on the Texas Serious Illness Institute actuarial analysis, this report recommends Texas HHSC to pursue a supportive palliative care Medicaid benefit through a State Plan Amendment (SPA) or other waiver authority. Palliative care is referred to as “supportive palliative care” in Texas statute but is defined the same and recognized as an independent service line from hospice care.
Given that palliative care can improve outcomes while reducing spending, additional states are continuing to take actions that support and expand palliative care:
- Hawaii is implementing the country’s first SPA for community palliative care approved by the Centers for Medicare and Medicaid Services (CMS) in 2024. In April 2025, the state released an updated implementation memo to guide health plans as they begin to comprehensively cover community palliative care services for Medicaid beneficiaries.
- New Jersey passed legislation in 2023 to cover community-based palliative care benefits under Medicaid. Intending to follow in Hawaii’s footsteps, the state is exploring a SPA to fulfill the legislation’s mandate.
- New York newly released its Master Plan for Aging. The plan contains a proposal to expand access to community palliative care for Medicaid recipients, among additional palliative care recommendations.
- Washington is legislatively mandated to convene a workgroup to design a palliative care benefit for fully insured health plans. The state is working to develop a standard of care across coverage types.
Conclusion
Some states are leading the way in palliative care coverage, which creates opportunities for other states to learn from their work, particularly as new policies are implemented. NASHP will continue to provide guidance to the states that participated in the Institute as well as additional states working on palliative care policy for Medicaid beneficiaries.
More from NASHP on Palliative Care
To stay up to date on NASHP’s palliative care work and states’ palliative care progress, subscribe to NASHP’s quarterly palliative care newsletter. And check out NASHP’s Palliative Care Resource Center for additional resources for states and 50-state trackers on palliative care legislation, councils, and education campaigns.
Acknowledgment
This brief and NASHP’s palliative care work is generously supported by The John A. Hartford Foundation. NASHP’s palliative care actuarial simulation is in partnership with TFA Analytics and CBIZ Optumas.
