How Do Patients Qualify for Hospice Care?

During an incredibly difficult time, hospice care provides important care, information and peace of mind for patients and their families. In fact, many families share that they wish they had summoned hospice care sooner.

When do patients qualify for hospice care?

When determining eligibility for hospice, a doctor must certify that the patient is terminally ill, with a life expectancy of six months or less if the disease runs its expected course. The hospice medical director must agree with the doctor’s assessment.

This is the primary criteria used for determining hospice eligibility for patients.

There are three (3) primary situations that precede a doctor recommending hospice care:

1. Lack of improvement. Despite treatment, the patient’s condition isn’t improving. The person isn’t feeling better and the illness has progressed to end-stage disease.

2. Goals of care have changed. For instance, often a patient realizes they are not getting better and doesn’t want to be in a hospital or go to a hospital anymore. Someone who’s becoming more and more anxious about the prospect of dying might also be referred for hospice care.

3. Acute health events. Patients who suffer from an acute event, like a heart attack or stroke, may require end-of-life care.

Once a doctor has referred the patient to hospice, a hospice nurse will visit and conduct a health assessment. Some common signs among patients who qualify for hospice include:

• Weight loss of 10 percent within the previous three to six months

• Insufficient hydration and nutrition or decreased ability to benefit from nutritional support

• Trouble swallowing

• Increasing shortness of breath

• Inability to perform most daily activities independently; spends most of the time in bed or a chair

• Increased fatigue and daytime sleeping

• Progressively worse incontinence

• Recurrent or multiple infections

• Increased cognitive impairment, confusion, unintelligible speech

• Increased visits to the hospital or ER, with limited improvement

• Rapid disease progression despite treatment

• Pain or emotional suffering

After this assessment, acceptance into hospice is “a team decision,” says Interim HealthCare National Director of Hospice Services Tammy Fox, RN, “but ultimately, eligibility rests with the hospice medical director.”

Once a person is deemed eligible for hospice, the patient must elect to receive it in place of curative care.

How are costs covered for hospice care?

Hospice is covered under the Medicare Hospice Benefit for patients who are covered by Medicare and eligible for Medicare Part A - Hospital Insurance. Income-eligible Medicaid patients also receive a hospice benefit.

Most private insurance companies provide some degree of hospice coverage as well. The Veterans Health Administration provides hospice coverage similar to Medicare for eligible United States veterans.

Approval of services from a doctor and hospice team are critical for any of these benefits to be paid for hospice care. Without them, most costs associated with hospice care will require out-of-pocket payment.

What if a person lives beyond six months while in hospice care?

Medicare patients are entitled to an unlimited number of 60-day benefit periods after the initial six months, if they are recertified as terminally ill with a prognosis of six months or less. The process of meeting with and being evaluated by the hospice care team will need to be repeated.

According to the Medicare Rights Center, meetings to reapply for hospice care should take place before the end of the current benefit period but no sooner than 30 days before the next period. If hospice care is being provided by private insurance, make sure you understand your insurance company’s policies about continuing coverage.

Providing support and dignity to patients and their families.

Thinking about hospice care is never easy, but here at Interim HealthCare, we work together with patients, their families and hospitals to provide exceptional care and support. To speak with a compassionate Interim HealthCare representative in your community, use the locator to find your local Interim HealthCare location.