Hospice Eligibility

In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and certified as being terminally ill by a physician and having a prognosis of 6 months or less if the disease runs its normal course.

42 CFR 418.20 418.20 Eligibility requirements.

Hospice Pre-Election Evaluation and Counseling Services (CR 3585) - Medicare allows for a one time visit by a physician who is either the medical director of or employee of a hospice agency to:
Evaluate the individual's needs for pain and symptom management
Counsel the individual regarding hospice and other care options
Advise the individual regarding advanced care planning

In order to be eligible to receive this service, a beneficiary must:

Be determined to have a terminal illness (which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course;
Not have made a hospice election, and
Not previously received the pre-election hospice services

Eligibility and the Local Coverage Determinations (LCDs)

The LCDs for the hospice's geographic areas are used as guidelines to help a physician determine hospice eligibility. The LCD's are not regulations and should not be used exclusively to determine or provide evidence of hospice eligibility. Certification or recertification is based upon a physician's clinical judgment, and is not an exact science. Congress made this clear in section 322 of the Benefits Improvement and Protection Act of 2000 (BIPA), which says that the hospice certification of terminal illness "shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness."

General Guidelines

Multiple Falls
Uncontrolled or Increased Pain
Frequent Emergency Room Visits
Recent / Frequent Hospital Visits
Progressive Weight Loss
Deteriorating Mental Abilities
Recurrent Infections
Decline in Activities of Daily Living (ADL's)
Overall Decline In Condition

Who Pays for Hospice

Medicare and Medicaid both have a hospice benefit that will pay for most, if not all, hospice services related to the terminal diagnosis. The patient will continue to be covered by Medicare,Medicaid or their private insurance for treatment of any unrelated diagnosis or medical problems.