When is someone eligible for hospice care?

Medicare, Medicaid and most insurance plans provide coverage for hospice care when physicians predict a patient has six months or less to live, and curative treatment is no longer being sought. This six-month prognosis is merely a guideline. Hospice re-evaluates patients every 60 days. Patients can be recertified for hospice coverage as long as they continue to meet hospice Medicare guidelines.

Illnesses that may qualify for hospice care include, but are not limited to:

• Metastatic Cancers
• Heart Disease
• Kidney Disease
• Liver Disease
• Lung Disease Stroke and/or Coma
• AIDS
• Neurological Diseases (Alzheimers, Parkinsons, Dementia)
• Lou Gehrigs Disease (ALS)
• Failure of Multiple Organ Systems
• Failure to Thrive

An unfortunate misconception about hospice is that the use of hospice care somehow guarantees the patient has less than six months to live. Medicare defines the hospice standards that are used by Medicare hospice providers and most private insurance companies. According to Medicare: “Generally speaking, the hospice benefit is intended primarily for use by patients whose prognosis is terminal, with six months or less life expectancy. However, the Medicare program recognizes that terminal illnesses do not have entirely predictable courses.”

Medicare’s benefit is not limited in terms of time. Hospice care is available as long as the patient’s prognosis meets the law’s six-month test. This test is a general one, based on the attending physician’s and/or medical director’s clinical judgment regarding the normal course of the individual’s illness.

Under this philosophy, Medicare has specified a procedure for certification and periodic recertification of the patient’s eligibility for care under the Medicare Hospice Benefit. This procedure provides two 90-day eligibility certification periods followed by an unlimited number of 60-day eligibility certification periods.