Hospice care is a specialized form of medical and emotional support focused on comfort and quality of life for individuals facing a terminal illness. It provides palliative care aimed at managing symptoms and pain, rather than curative treatment. Hospice programs can refuse a patient, both upon initial application and after care has begun. This ability to refuse or discharge a patient is governed by strict regulations and medical necessity standards.
Refusal Based on Clinical Eligibility
The most frequent reason for refusal is that the applicant does not meet the established clinical eligibility criteria. To qualify for hospice under the Medicare benefit, a patient must have a terminal illness with a prognosis of six months or less to live, assuming the disease runs its expected course. This prognosis is an informed medical judgment, not a guarantee of life expectancy.
The prognosis must be formally certified by two physicians: the patient’s attending doctor and the hospice medical director. Certification requires specific documentation of disease progression and observable signs of decline. If the documentation is insufficient or the patient’s condition does not demonstrate progressive decline, the hospice must refuse admission due to a lack of medical necessity for hospice-level care.
Objective indicators often support a terminal prognosis. These include significant unintentional weight loss, a decline in functional status (e.g., a low Palliative Performance Scale score), or an increase in disease-related events like hospitalizations. If a patient’s condition is stable or improving, they do not meet the definition of being terminally ill for the hospice benefit. Refusal in this instance is a regulatory requirement tied to the definition of coverage.
Administrative and Safety Reasons for Non-Acceptance
A hospice provider may refuse a patient for logistical, capacity, or safety reasons, both at intake and as a cause for involuntary discharge. One common initial refusal is geographical; each hospice operates within a defined service area, and if an applicant lives outside that boundary, the provider cannot accept them. A hospice may also temporarily refuse new admissions if they have reached their maximum safe patient capacity, ensuring adequate staffing and resources for existing patients.
The Medicare Hospice Conditions of Participation permit involuntary discharge for three legally defined reasons. The first is if the patient’s condition significantly improves and they are no longer considered terminally ill, removing clinical eligibility. The second is if the patient moves out of the hospice’s designated service area and does not transfer to another provider.
The third reason is a “discharge for cause,” relating to the safety of the hospice staff or the ability to deliver effective care. This applies when the patient or a person in the patient’s home engages in disruptive, abusive, or uncooperative behavior that severely impairs the hospice’s operations. Before initiating this discharge, the hospice must advise the patient that discharge is being considered, make a serious effort to resolve the underlying problem, and thoroughly document all efforts in the medical record.
Patient Rights and Finding Alternative Care
When a hospice determines a patient is no longer eligible or must be discharged, the patient and family have rights to challenge that decision. For Medicare beneficiaries, the hospice must provide a Notice of Medicare Non-coverage, explaining the decision and outlining the appeal process. Patients can request an expedited determination, or “fast appeal,” from the independent third party known as the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO).
The BFCC-QIO reviews the medical records and the hospice’s justification to determine if the discharge is appropriate. During this appeal process, the patient often has the right to continue receiving hospice services until the independent review organization makes its decision. If the hospice’s decision to discharge is upheld, the patient’s Medicare coverage for the terminal illness reverts to standard benefits. If a patient is discharged due to medical improvement, they return to curative care, and standard Medicare benefits resume. If the patient was refused or discharged for a non-clinical reason, such as service area limits or capacity, the family can simply contact a different hospice provider in their area. Those who lose clinical eligibility can re-elect the hospice benefit if their condition declines and they once again meet the six-month prognosis requirement.