How do you Qualify for Hospice Care?

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how to qualify for hospice
Published:  January 1, 2022

As patients progress through a terminal illness, many will turn to hospice care. This is a philosophy of care that treats the individual rather than the disease, with a strong focus on the quality of life. In addition to making people more comfortable, it also addresses the emotional and spiritual issues that they and their loved ones are facing.

Patients will be assigned a hospice team meant to address all aspects of their comfort and well-being, including doctors and nurses as well as social workers, hospice aides, volunteers, grief counselors, and chaplains.

Hospice services can be given to patients wherever they reside, whether they are in their own homes or living with a family member, at an assisted living facility, or in a hospital. However, there are some requirements that must be met before patients become eligible for hospice care.

Qualifying for Hospice Care

There are two main qualifications for hospice. First, at least two physicians need to certify that a patient has a terminal illness and that their life expectancy is less than six months if their disease takes its normal course.

Some of the illnesses that may fall under this category include dementia, liver disease, stroke or a cerebral vascular accident, cancer, AIDS, congestive heart failure, cardiopulmonary disease, renal disease, and neurological conditions such as Parkinson’s disease, Huntington’s disease, and multiple sclerosis.

Second, the patient and/or their family must be aware of this prognosis and deliberately choose to undergo hospice care rather than focusing on active curative treatment.

Eligibility Requirements

Medicaid hospice eligibility and benefits vary by state but generally require a doctor’s certification of terminal illness, a patient’s agreement to switch from curative treatment to hospice care (unless they are younger than 21 years old), and a statement of reduced life expectancy by a doctor.

Medicare has similar requirements like a diagnosis of six months or less to live and the desire to choose comfort care over curative treatment for patients needing Medicare Part A coverage. In addition to covering hospice services, Medicare also covers a pre-election evaluation and counseling service for patients.

Although most patients will use Medicaid or Medicare to cover their hospice services, some opt to use their private health insurance plan instead. Many plans will cover the full cost of hospice services, but the requirements vary. The minimum requirement is a reduced life expectancy of fewer than six months and a terminal illness diagnosis; some will also require the patient to discontinue any curative measures before starting hospice care.

Here is a look at some of the other eligibility criteria that may apply.

The Patient Is Diagnosed with Life-Limiting Condition

When a patient has been diagnosed with a life-limiting condition, they generally qualify for hospice when they have less than six months to live. However, there are some conditions that may apply to specific illnesses.

A Palliative Performance Scale is sometimes used to assess a patient’s progressive decline to determine hospice eligibility. Expressed as a percentage of up to 100, it evaluates a patient’s ambulation level, activity level, evidence of disease, intake, consciousness level, and self-care ability. A similar scale known as the Karnofsky scale may also be used.

For cancer patients, some of the criteria used to determine whether hospice is appropriate, include a decline in their condition despite therapy, metastatic cancer, and a Palliative Performance Score of 70% or less. Patients with some cancers, such as pancreatic and small cell lung cancer, are often eligible for hospice without the presence of other criteria.

For dementia patients, it can be more difficult to determine eligibility because the disease progresses slowly. Although there is no set number of symptoms that a patient must experience to become eligible, hospice is generally considered when the person is also diagnosed with other conditions like pneumonia or sepsis, speaks fewer than six words per day, has trouble swallowing or frequently chokes on foods or liquids, cannot sit upright, or walk without assistance or loses the ability to smile.

Frequent Hospital Visits Within the Last 6 Months

A spike in hospitalizations and ER visits in the past six months can be a signal that it may be time to consider hospice. This generally indicates that a disease has progressed toward its end stages and additional help is required.

Consistent Weight Loss

Consistent and progressive weight loss is another indication that hospice may be necessary. Weight loss is generally associated with a decline in condition and is especially concerning if it amounts to 10 percent or more of a person’s body weight in the last six months after accounting for edema weight. A decline in anthropomorphic measurements may also be an indication of disease progression.

Increase Of Weakness and Fatigue

Increases in sleepiness, fatigue, and weakness can also be considerations for hospice eligibility. Worsening symptoms in general and responding poorly to treatment are also factors to take into account.

Traditions Health is Ready to Support You

If you are considering hospice care for yourself or a loved one, get in touch with the hospice professionals at Traditions Health today to find out more about the benefits and determine if it is right for your case.

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