Hospice Criteria

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 (if the disease runs its usual and normal course) 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, Veteran’s Administration, Blue Cross Blue Shield, etc.

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

  • 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 or dementia
  • Cancer
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes
  • Failure to thrive
  • 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.