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Hospice Eligibility

(Non Discrimination Notice Policy - updated 2016)

A common misconception about hospice is that it is a service provided only to cancer patients. The fact is that we provide care to patients with any end stage diagnosis. These may include, but are not limited to:

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  • Metastatic Malignancies
  • Heart Disease
  • Kidney Disease
  • Liver Disease
  • Lung Disease
  • Stroke and/or Coma
  • AIDS
  • Neurological Diseases (Alzheimer’s, Parkinson’s, Dementia, etc.)
  • Lou Gehrig’s Disease (ALS)
  • Failure of Multiple Organ Systems
  • Failure to Thrive
  • Debility and Decline

Is it true that you must have only six months to live to be eligible for the Medicare Hospice Benefit?
Another common, and 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, Pennsylvania hospice providers and most private insurance companies. Medicare has provided the following explanation and clarification regarding the hospice benefit eligibility guidelines.

“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.”

“Recognizing that prognoses can be unpredictable and may change, 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. Medicare recognizes that making medical prognostications of life expectancy is not always an exact science.”

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. As long as the patient, in the judgment of the primary physician and hospice Medical Director, continues to meet the six month criteria during each certification period, the patient can continue to receive care under the Medicare Hospice Benefit.

When does hospice care become appropriate?
Hospice care becomes appropriate when an individual has a life-limiting illness or condition. The patient’s primary physician and the Hospice of the Sacred Heart Medical Director will work together to make this medical determination. The patient and family then determine whether the patient wishes to enter the hospice care program.

The following guidelines are used to assist the physician and hospice Medical Director in making a judgment regarding an individual’s eligibility for hospice care.

The patient has a declining functional status as determined by either:

  • A Karnofsky Performance Status of 50% or less (The Karnofsky Performance Status is an evaluation that assesses a person’s ability to function independently)
  • Dependence in 3 out of 6 Activities of Daily Living
  • Frequent hospitalizations
  • Frequent trips to the Emergency Room
  • Weight loss of 10% or more in the last 4 to 6 months
  • Serum Albumin less than 2.5 gm / dl (Albumin is a component of protein and makes up one half of plasma protein)
  • Patient and family have elected comfort care rather than curative treatment

Informal Hospice Eligibility Questionnaire
We have also prepared the following brief questionnaire that can help you determine whether hospice care is right for you or your loved one.

You or your loved one may be eligible for hospice care if you check 4 or more statements. However, your primary physician and our Medical Director will make the final decision regarding eligibility.

Please review the following statements as they apply to you or your loved one to see if hospice care may be appropriate.

  • I have started feeling more tired and weak
  • I experience shortness of breath, even when resting
  • I spend most of the day in bed or in a chair
  • I have noticed an increased weight loss in the past six months
  • I make frequent phone calls to my physician
  • I take medications to lessen physical pain
  • I have fallen several times in the past six months
  • I have made frequent trips to the emergency room in the past six months
  • I need help from others with important daily activities (bathing, dressing, eating, cooking, walking, getting out of bed)
  • My doctor has told me my life expectancy is limited

If you have checked 4 or more items on the questionnaire, you may want to begin your research into hospice care by seeking the opinion and advice of your (or the affected individual’s) primary physician. If you do not have a primary physician, we will be happy to refer you to our Medical Director, who is a Doctor of Internal Medicine.