What Are the Hospice Eligibility Criteria?

Most people want to spend their last days at home, and this should be possible for most. That’s because the type of care that allows people to die at home – hospice care – usually has no out-of-pocket cost if you’re eligible through Medicare, Medicaid or private insurance. So, how do you know if you’re eligible for hospice care? Let’s discuss in more detail.

Is it Time to Ask About Hospice Care?

Before learning whether you or a loved one are eligible for hospice care, you may be wondering if it’s even time to seek help from hospice. Choosing hospice is a personal and complex decision.

There are some signs that a person may be nearing the end-of-life that can help you know it may be time for hospice care:

• Progressive weight loss
• Frequent hospitalizations
• Increasing weakness or fatigue
• Recurring infections
• Significant difficulty with daily activities like bathing and dressing

Some common Medicare hospice diagnoses include dementia, lung disease, COPD, cancer, heart disease, liver disease and Parkinson’s disease.

It’s also important to consider whether you are fully ready both emotionally and mentally to make the hospice choice. Some important signs of emotional readiness include:

• Acceptance of terminal diagnosis: You’ve come to terms with the reality of your condition and its progression.
• Desire for comfort over cure: You prioritize relief from pain and symptoms rather than aggressive treatments.
• Peace with end-of-life decisions: You’ve made or are making decisions about advance directives, funeral planning or legacy matters.
• Reduced fear of dying: You feel less anxious about death and more focused on meaningful moments.
• Seeking emotional closure: You’re motivated to resolve conflicts, express love and say goodbye to loved ones.
• Spiritual reflection or readiness: You’re engaging in spiritual or existential contemplation, regardless of religious beliefs.
• Willingness to receive support: You’re open to emotional, psychological and spiritual care from hospice professionals.

If you change your mind and decide to pursue curative treatment, you can stop hospice care at any time. Who meets the hospice qualifications depends on what kind of healthcare coverage you have.

The Medicare Hospice Benefit

The Medicare Hospice Benefit covers the cost of hospice care, including medications, medical supplies and equipment related to the hospice diagnosis. For example, for a hospice patient with cancer, Medicare could cover medications and therapies related to their cancer diagnosis but would not cover chemotherapy to try to cure their cancer.

Most adults age 65 and older pay for hospice through the Medicare Hospice Benefit. ¹ Patients have to meet all of Medicare’s hospice eligibility criteria, which include:

1. Your doctor certifies that you have a terminal illness, with six months or less to live if the disease runs its normal course.

A person is considered terminally ill if their life expectancy is six months or less if the disease runs its normal course. This is based on your doctor’s clinical judgment. If you live longer than six months and still qualify for hospice, your doctor can re-certify you to stay on hospice. ² If your illness goes into remission or you are no longer terminally ill, you will be discharged from hospice (as required by law). If you decide you no longer want hospice or decide you want to pursue curative treatment again, you can make the choice to stop hospice at any time.

2. You’re ready to stop treatments to cure your illness and elect the hospice benefit, instead focusing on treatments that improve your comfort and quality of life.

When you elect the Medicare Hospice Benefit, you choose hospice care, or “comfort care,” rather than trying to cure your illness. Working with a team of nurses, physicians, aides, social workers and other specialists, hospice care focuses on pain and symptom management, helping you meet your goals and wishes for end-of-life care.

3. Your hospice provider is Medicare-approved.

The Medicare Hospice Benefit applies only to approved hospice agencies. To become certified, hospice agencies have to meet certain federal requirements. You can find Medicare-approved hospice agencies and compare their quality scores on the Care Compare website.

The Medicaid Hospice Benefit

Medicaid provides free or low-cost health insurance for the elderly, low-income families and other groups. Although coverage varies state to state, the Medicaid Hospice Benefit is generally similar to the Medicare Hospice Benefit. ³ It can be used along with your Medicare coverage. You can also use your Medicaid coverage for other health issues not associated with your terminal diagnosis.

Much like the Medicare Hospice Benefit, under Medicaid, hospice care requirements typically include:

• You’ve been diagnosed with a terminal illness; and
• Your doctor certifies that you have six months or less to live if the disease runs its normal course; and
• You’re ready to stop treatments to cure your illness, instead focusing on treatments that improve your comfort and quality of life; and
• Your hospice provider is Medicaid-approved.

Private Insurance for Hospice

If you have a private health insurance plan through a retirement program, employer or the Affordable Care Act, it probably covers hospice care. Every insurance plan is different and has unique hospice eligibility requirements. Like the Medicaid and Medicare Hospice Benefits, most plans require that:

• You’ve been diagnosed with a terminal illness, and
• You’re ready to stop treatments to cure your illness, instead focusing on treatments that improve your comfort and quality of life.

Most insurance plans cover 100% of hospice costs, just like the Medicare Hospice Benefit. Contact your insurance provider to avoid unexpected charges.

Do You Qualify for Hospice? Find Out Your Hospice Eligibility

Those who meet hospice eligibility requirements can get comprehensive end-of-life care. Hospice care includes physicians, nursing, home health aides, medical social services, counseling services, support for family members and caregivers, and more. Under both the Medicaid and Medicare Hospice Benefit, you can receive hospice care in a residence, a facility or wherever you call home.

Do you think you or a loved one might need hospice care? You don’t have to make this decision alone. Call the Amedisys hospice care center near you to talk through your options with a hospice specialist. If you’re eligible, getting hospice care sooner rather than later can help you get more of what matters most to you.

Deb Gallaher, MBA, MSN, RN, NE-BC, CHPN, is a Senior Hospice Clinical Education Specialist for Amedisys. She has 10 years of experience in hospice and is passionate about sharing her insights on high-quality care.