Hospice care is a specialized form of interdisciplinary support focused on providing comfort and managing symptoms for individuals nearing the end of life. This care shifts the focus from aggressive, life-prolonging treatments to maximizing the quality of the remaining time for the patient and their family. It involves a team approach that addresses the medical, emotional, and spiritual needs of the person with a terminal illness, requiring them to meet defined criteria established primarily through federal health care standards.
The Six-Month Prognosis Requirement
The most fundamental criterion for hospice admission is a medical prognosis estimating a life expectancy of six months or less, based on the terminal illness running its usual, expected course. Patients may continue receiving care if they live longer than six months, as this estimate is not a guarantee of a timeframe.
Formal certification of this prognosis is required by two physicians: the patient’s attending physician (if applicable) and the hospice medical director or a designated hospice physician. This certification must confirm the patient is terminally ill and that the six-month projection is supported by clinical documentation. This documentation often includes evidence of declining functional status, such as a drop in the Palliative Performance Scale (PPS) rating or increased dependence on others for daily living activities.
The terminal illness must be a specific diagnosis that is the primary contributor to the limited life expectancy. Common examples include advanced cancer, end-stage heart or lung disease, or progressive neurological disorders. Supporting factors often include significant weight loss, frequent hospitalizations, or a decrease in tolerance for physical activity.
Choosing Palliative Care
A second major requirement for hospice eligibility is the patient’s formal election of palliative care over curative treatment for the terminal illness. Electing hospice requires the patient or their authorized representative to sign a statement acknowledging this choice and agreeing to forgo medical interventions intended to stop or reverse the progression of the terminal disease.
Palliative care, in this context, is defined as comfort care focused on pain and symptom management. This approach aims to provide the best possible quality of life without the burden of aggressive treatments.
Care for conditions unrelated to the terminal illness is still covered, countering the common misunderstanding that all medical care ceases upon hospice election. For example, a patient with end-stage lung disease may still receive antibiotics for a urinary tract infection or medication for high blood pressure. This allows for the treatment of concurrent, non-terminal issues while maintaining the focus on comfort for the primary illness.
Programmatic Eligibility and Coverage Standards
For most Americans, the criteria for hospice are intrinsically linked to the Medicare Hospice Benefit (MHB), which defines the national standard for eligibility and coverage. To qualify for MHB, the patient must be entitled to Medicare Part A and receive care from a Medicare-certified hospice provider. Although Medicaid and private insurance plans may have slight variations, they generally follow the structure established by Medicare.
The MHB is structured into defined benefit periods that dictate the required certification schedule. Initial coverage consists of two 90-day periods, which together cover the initial six-month prognosis. Following these two periods, the patient may receive an unlimited number of subsequent 60-day periods, provided they continue to meet the clinical criteria. The patient’s election of the benefit is a foundational legal step, formally waiving their right to Medicare payment for curative treatments related to the terminal condition.
Recertification for Extended Care
If a patient’s health stabilizes or the terminal illness progresses more slowly than initially estimated, they are not automatically discharged when the initial six months elapse. Continued care is maintained through a process of recertification at the beginning of each new benefit period.
For the third benefit period and all subsequent periods, the recertification process includes an additional requirement: a face-to-face encounter between the patient and a hospice physician or nurse practitioner. This encounter must occur within 30 days prior to the start of the new period. Documentation from this visit must specifically attest that the clinical findings continue to support a life expectancy of six months or less if the terminal illness runs its normal course.