Patient Eligibility for Medicare and Medical Hospice Benefits

Patient Eligibility for Medicare/Medicaid Benefits

Patient must be eligible for Medicare Part A (the hospitalization benefit)
Patient must have a “terminal illness,” the prognosis being 6 months or less based on the patient’s condition at the time of diagnosis, as certified by the patient’s primary care physician
Patient or family (if the patient is unable to decide by themselves) must give informed consent
Care must be provided by a Medicare-certified hospice licensed by the department of Health
Hospice benefits can also be obtained through private, for-profit insurance policies such as HMOs, BC/BS, K/M, HP, etc.

Guidelines for Medical Eligibility

These guidelines will help you determine medical eligibility for hospice benefits. The following characteristics should be present before the patient enters into a hospice program.

General Guidelines

The patient's expected life span of 6 months or less is based on the patient’s condition at the time of diagnosis. The patient must show persistent decline during this time in order to remain on hospice care. If patient's condition improves, patient can be discharged from hospice services. The services can be resumed at any time as the patient's condition worsens.
The patient must have a life limiting condition in order to qualify for hospice care
The patient/decision maker must desire palliative approach rather than curative focus
The progression of disease must be documented:
- By disease specific markers—physical examination, labs, imaging
- Multiple hospital admissions or ER visits
- Decline in functional status
- Impaired nutritional status
- Physician's best medical opinion
There are specific criteria for hospice eligibility for a variety of conditions, including:
- ALS
- Alzheimer’s/Dementia
- Cancer
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetes
- Failure to Thrive
- HIV/AIDS
- Kidney (Renal) Disease
- Liver Disease
- Unspecified Debility (Non-Specific Terminal Illness)
- Heart Disease
- And others

A patient may also qualify for the Medicare Hospice Benefit under two or more diagnoses.

If you would like more information on specific medical criteria for a particular medical condition (or conditions), please contact us.

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Patient Eligibility for Medicare/Medicaid Benefits

Guidelines for Medical Eligibility