Hospice Eligibility

Hospice Eligibility and Admission Criteria

In accordance with the Medicare Benefit Policy Manual:

In order for an individual to be eligible to elect hospice care under Medicare, they must be entitled to Medicare Part A and be certified as being terminally ill by a physician. An individual is considered to be terminally ill if the physician’s medical prognosis is that the patient’s life expectancy is 6 months or less should the illness run its normal course. Medicare only covers care provided by (or under arrangements made by) a Medicare-certified hospice.

This hospice care provider only admits patients on the recommendation of the medical director in consultation with, or with input from, the patient’s attending physician, if applicable.

In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information:

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(1) Diagnosis of the terminal condition of the patient.

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(2) Other health conditions, whether related or unrelated to the terminal condition.

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(3) Current clinically relevant information supporting all diagnoses.

Section 1814(a)(7) of the Social Security Act (the Act) specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual’s attending physician, if he/she has one, regarding the normal course of the individual’s illness. No one other than a medical doctor or doctor of osteopathy can certify or re-certify a terminal illness. Predicting of life expectancy is not always exact. The fact that a beneficiary lives longer than expected in itself is not cause to terminate benefits. “Attending physician” is further defined in section 20.1 and 40.1.3.1. An individual (or his authorized representative) must elect hospice care to receive it. The first election is for a 90-day period.

An individual may elect to receive Medicare coverage for two 90-day periods, and an unlimited number of 60-day periods. If the individual (or authorized representative) elects to receive hospice care, he or she must file an election statement with a particular hospice. Hospices obtain election statements from the individual and file a Notice of Election with the Medicare contractor, which transmits them to the Common Working File (CWF) in electronic format. Once the initial election is processed, CWF maintains the beneficiary in hospice status until a final claim indicates a discharge (alive or due to death) or until an election termination is received.

Throughout the duration of the hospice care, an individual must waive all rights to Medicare payments for the following additional services:

Hospice care provided by a separate provider other than the original hospice designated by the individual (unless provided under arrangements made by the designated hospice) ;

AND

Any Medicare services rendered that are in relation to the treatment of the terminal condition for which hospice care was originally appointed or a related condition, or services that are equivalent to those provided by the hospice, except for services provided by:

1. The designated hospice (either directly or under arrangement);

2. Another hospice under arrangements made by the designated hospice; or

3. The individual’s attending physician, who may be a nurse practitioner (NP) or a physician assistant (PA), if that physician, NP, or PA is not employed by the designated hospice or being compensated from the hospice for any services.