Hospice care is a specialized form of comfort-focused, end-of-life care for individuals facing a terminal illness. It provides comprehensive medical, emotional, and spiritual support, prioritizing quality of life over curative treatments. While hospice is a benefit designed to be accessible to qualifying individuals, providers can refuse to admit a patient. This refusal is not arbitrary; it must be based on specific, regulated criteria related to the patient’s medical condition, the hospice’s operational capacity, or payment parameters.
Clinical Eligibility Requirements
The most common reason a hospice provider might refuse a patient is a failure to meet the strict clinical eligibility requirements set by the Centers for Medicare & Medicaid Services (CMS). To qualify for the Medicare Hospice Benefit, a patient must be certified as terminally ill, meaning a physician believes they have a prognosis of six months or less to live if the illness runs its expected course. This prognosis must be certified by two physicians: the patient’s attending physician and the hospice medical director or physician.
The hospice provider is legally obligated to ensure the patient meets this narrow medical definition. The terminal illness must be documented with specific clinical evidence of decline, such as significant, unintentional weight loss, frequent hospitalizations, or a rapidly deteriorating functional status, often measured by a Palliative Performance Scale (PPS) rating. Since hospice care provides palliative rather than curative treatment, a patient not meeting this strict medical threshold must be refused admission.
Administrative and Capacity Limitations
Refusal may occur not because of a patient’s medical status, but due to logistical or resource constraints within the hospice organization. Most hospices operate within a defined service area, and if a patient resides outside that established geographic boundary, the hospice may decline admission. This limitation is due to the practical challenges of providing timely, continuous care to a patient who is too far away for staff to reach quickly, especially during emergencies.
A hospice may also refuse care if the patient’s needs exceed the provider’s licensed capacity, specialized capabilities, or staffing level. For example, a patient requiring highly complex, specialized care or exhibiting severe, unmanageable behavioral health issues that the hospice staff is not trained or equipped to handle may be refused. Furthermore, a hospice may reach maximum capacity due to staffing shortages or a lack of available beds in its inpatient unit, forcing them to temporarily pause new admissions.
Financial and Coverage Considerations
While a patient cannot be denied care based on their source of payment, refusal can occur if the patient has not properly elected the Medicare Hospice Benefit or if their chosen payment structure conflicts with hospice rules. The Medicare Hospice Benefit requires the patient to waive coverage for all curative treatments related to the terminal diagnosis, choosing comfort care instead. If a patient insists on simultaneously pursuing aggressive, life-prolonging treatments for the terminal condition, they are not eligible for the benefit, and hospice must refuse admission.
Refusal can also result if the patient’s specific insurance provider does not have a contract with the hospice agency, although this is less common for hospices accepting Medicare and Medicaid. Patients who are not eligible for Medicare and have private insurance must have their plan’s coverage verified. If the hospice cannot secure payment, they may refuse admission.
Refusal at Intake vs. Patient Discharge
It is important to distinguish between being refused at the time of intake and being discharged after a period of care. Refusal at intake occurs when a patient does not meet the initial clinical, administrative, or financial criteria for admission. Discharge, however, is the termination of services after the patient has already been admitted and is governed by strict federal regulations.
A patient can be discharged involuntarily if their condition improves to the point where they no longer meet the six-month prognosis, as determined by the hospice physician. Other regulated reasons for discharge include the patient moving out of the hospice’s service area or disruptive behavior that compromises the ability to deliver care, only after documented attempts to resolve the issue. If a patient is refused at intake, the family should seek a second medical opinion on the prognosis or contact a different hospice provider. If a patient is discharged, they resume standard Medicare coverage and can re-elect the hospice benefit if their condition declines again.