Hospice care is a specialized form of interdisciplinary support designed to provide comfort, enhance quality of life, and manage symptoms for individuals facing the end of life. The focus shifts from attempting to cure a terminal illness to providing palliative care, which addresses physical, emotional, and spiritual needs. Qualification involves meeting specific medical and administrative requirements to ensure the care is appropriate and covered by insurance. This process confirms the patient will benefit most from a comfort-focused approach rather than continued aggressive curative treatment.
The Terminal Illness and Prognosis Requirement
The foundational requirement for hospice qualification is a medical determination that the patient is terminally ill. This means the illness is no longer responding to curative treatments and is expected to run its natural course. The specific criterion tied to this status is a prognosis, or medical forecast, that the patient has a life expectancy of six months or less.
This six-month timeframe is a benchmark based on the expected progression of the illness. Clinical indicators beyond the primary diagnosis, such as frequent hospitalizations, significant unintentional weight loss, or a marked decline in functional abilities, help support this prognosis. A decline in a patient’s Palliative Performance Scale (PPS) rating or increased dependence on others for Activities of Daily Living (ADLs) suggests a worsening condition.
Qualification requires the patient to agree to forgo further medical interventions specifically aimed at curing the terminal illness. This shift prioritizes symptom control and comfort. A patient may still receive treatment for conditions unrelated to the terminal diagnosis while under hospice care.
The Physician Certification Process
The medical prognosis must be formally documented through a two-part certification process involving physicians. Initially, the patient’s attending physician (if they have one) and the hospice medical director must both certify in writing that the patient is terminally ill with a six-month or less prognosis. This certification can be completed up to 15 days before the patient officially elects hospice care.
The physicians must provide a brief narrative explaining the clinical findings that support this terminal prognosis. This written statement validates the medical necessity of hospice services. If written certification cannot be obtained immediately upon admission, a verbal certification must be secured within two calendar days, followed promptly by the required written documentation.
Once a patient is admitted, the prognosis must be periodically re-certified to continue receiving the benefit. The initial period of care is followed by a second 90-day period, and then by subsequent 60-day periods. For these recertifications, only the hospice medical director or a hospice physician is required to sign the certification, confirming the patient’s continued eligibility.
To support recertification for the third benefit period and all subsequent periods, a physician or nurse practitioner must conduct a face-to-face encounter with the patient. This visit must occur no more than 30 calendar days before the start of the new benefit period to gather clinical evidence of the patient’s ongoing decline.
Understanding Coverage Eligibility Rules
For most people, hospice qualification is administered under the guidelines of the Medicare Hospice Benefit. The benefit is available under Medicare Part A for individuals who meet the terminal illness criteria and choose comfort care instead of curative treatment for their terminal condition. Medicaid and most private insurance plans largely mirror these federal guidelines for their own hospice coverage.
Eligibility under Medicare requires the patient to sign a statement officially electing the hospice benefit. By signing this document, the patient formally agrees to waive Medicare payment for any services related to the terminal illness that are not provided by or arranged through the designated hospice provider. This ensures a clear delineation between comfort-focused care and curative care.
The benefit structure starts with two 90-day periods, followed by subsequent 60-day periods, provided the patient continues to meet the medical criteria. This structure allows for continued care for those who live longer than initially expected, with each new period requiring recertification to confirm the ongoing terminal status.
This financial framework reinforces the medical requirement by making payment dependent on the formal acceptance of palliative care. While the patient waives coverage for curative treatments, Medicare continues to cover services unrelated to the terminal illness, such as treatment for a broken bone or a separate infection.
Patient Rights: Electing and Revoking Hospice Care
Once a patient is medically certified as terminally ill, the decision to enter hospice is voluntary and documented through the signed election statement. The patient has the right to choose their attending physician and to select the Medicare-certified hospice provider they wish to use.
A patient has the right to revoke, or terminate, their hospice election at any time, for any reason. This decision must be communicated to the hospice provider through a signed written statement of revocation; a verbal request is not considered formal.
By revoking the benefit, the patient immediately reinstates their original Medicare coverage for all services, including those aimed at curing the terminal illness. If the patient wishes to re-enter hospice care, they may do so provided they are again certified as meeting the terminal prognosis criteria.