If you or a loved one have received a terminal diagnosis or have experienced a sudden decline in health, your entire family is probably feeling sad, stressed, and emotionally drained. To help you through this difficult season of emotional ups and downs, hospice care may be just what your family needs. But what are the eligibility requirements? Who qualifies and how? Let’s take a deeper look.
Two Basic Eligibility Requirements
1. Certification of Illness
A person is eligible for hospice if they have been diagnosed with a terminal illness and given less than six months to live. The primary physician and the hospice’s medical director will discuss the person’s illness and certify that the person has six months or less to live.
When determining eligibility and certifying illness, the primary physician and hospice medical director often look for three indicators: 1) a patient’s lack of improvement despite treatment, 2) a patient’s goal becomes comfort rather than cure, and 3) acute health events, like heart attack or stroke.
Some common health symptoms that indicate a patient may qualify for hospice are:
- Frequent hospitalizations in the past six months
- Significant weight loss (10% or more) within the past 3-6 months
- A change in mental, cognitive, and functional abilities
- Increasing weakness and fatigue
- Decreasing appetite or trouble swallowing
- Inability to complete daily tasks, like eating, bathing, dressing, walking, etc.
- Recurring infections or increasing pain
- Insufficient hydration or nutrition
- A desire to stop treatment or to not go to the hospital
With some illnesses, often those that are long-term, the primary physician and hospice medical director will look for specific symptoms to help them determine if an illness has reached an end stage. This includes illnesses like ALS, Alzheimer’s and dementia, lung, heart, or liver disease, HIV/AIDS, cancer, neurological conditions, sepsis, and renal failure.
Let’s move on to the second eligibility requirement.
2. Focus on Comfort Rather than Cure
After an illness has been certified, there is one more eligibility requirement. Before a hospice care team can step in and begin to help the family, the terminally ill person must state that it is their intention to seek palliative care instead of curative care. This means that all care will now focus on improving quality of life and relieving pain rather than on life-prolonging treatments.
However, please note that you can stop hospice care at any time. If life expectancy improves or new treatments become available, you can stop hospice care and focus on curative care.
Alternatively, if hospice care isn’t working out for your family for whatever reason, you can stop it and do something else that may work better for your particular situation. If you need to re-enter hospice care at a later date, you can do so after the illness is re-certified.
Once your eligibility is confirmed, you can begin receiving services from your hospice care team. Care usually takes place at your home, but your insurance may cover other options so make sure to ask. To learn more about the basic services available to you through hospice, click here.
What if You Need Hospice Care for Longer than 6 Months?
Great question. Doctors don’t know exactly how an illness will affect each person individually. Because of this, a prognosis of six months may turn into a longer period of time. Hospice prepares for that.
Hospice care breaks up into benefit periods. You can receive hospice care for two 90-day periods, followed by an unlimited number of 60-day periods. However, at the end of every benefit period, doctors will reassess and recertify that hospice care is still needed.
If the end of a benefit period is approaching, start the reapplication process 30 days before the next period is set to begin. That will give you time to get everything approved, ensuring there is no lapse in care.
Now that you better understand how hospice eligibility works, your next step is to talk with your own or your loved one’s primary physician to determine next steps.
Please NOTE: These eligibility requirements are based on Medicare’s Hospice Benefit. Medicare pays for more than 85% of all hospice fees in the United States. If you have a different health insurance provider, call to ensure they don’t have additional eligibility requirements.
