Hospice Eligibility Guidelines

Most patients want to spend their last days at home, and this should be possible for most. Hospice care usually has no out-of-pocket costs if your patients are eligible through Medicare, Medicaid or private insurance. So, how do you know if your patients are eligible for hospice care?

The Medicare Hospice Benefit

Most adults age 65 and older pay for hospice through the Medicare Hospice Benefit if all of Medicare's hospice eligibility criteria are fulfilled. Criteria includes:

Physician-certified terminal illness, with six months or less to live if the disease runs its normal course.
Patients are ready to stop treatment to cure their illness and elect the hospice benefit.
Patients hospice provider is Medicare-approved.

The Medicaid Hospice Benefit

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

Patients have been diagnosed with a terminal illness.
Doctor has certified that the patient has six months or less to live if the disease runs its normal course.
Patients are ready to stop treatments to cure their illness.
Patients hospice provider is Medicaid-approved.

Refer a patient to home health or hospice seamlessly.

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Private Insurance for Hospice

Eligible patients who have a private health insurance plan through a retirement program, employer or the Affordable Care Act, are typically covered for hospice care. Much like the Medicaid and Medicare Hospice Benefits, most plans require that:

Patients have been diagnosed with a terminal illness.
Patients are ready to stop treatments to cure their illness.

Hospice Eligibility Guidelines By Disease

Patients may be eligible for hospice if they meet some of the below criteria and have significant co-morbidities and/or rapid decline, leading to a prognosis of six months or less as determined by their physician. Even if the patient does not meet any of these specific conditions, they may still be eligible for hospice if, in the judgement of the physician, the life expectancy is six months or less.

Please know that these are just examples and ultimately the physician must determine if a patient is terminal themselves.

General Guidelines
To be eligible for hospice, a patient with a terminal condition should exhibit one or more of the following:
- Disease progression that is not considered reversible.
- Multiple ER visits within the past 6 months.
- Progressive functional decline.
- Progressive impaired nutritional status.
Cancer
1. Disease with metastases at presentation, or
2. Progression from an earlier state to metastatic disease with the patient no longer seeking curative treatment, or continuing to decline in spite of therapy.
3. PPS < 70%
Liver Disease
1. PT prolonged more than 5 seconds over control or INR > 1.5
2. Serum albumin < 2.5 gm/dl
3. One of the following:
  - Ascites, refractory to treatment or patient non-compliant
  - Hepatic encephalopathy, refractory to treatment or patient non-compliant
  - Recurrent variceal bleeds
  - Spontaneous bacterial peritonitis
  - Hepatorenal Syndrome
Alzheimer's & Related Disorders
1. Stage 7 or greater on the FAST Scale. The Functional Staging Assessment Tool (FAST) is a common measure used to assess functional status in patients with dementia and determine appropriate care plans.
2. Comorbidity or secondary condition such as:
  - CAD/COPD/CHF (Comorbidities)
  - Pyleonephritis
  - Sepsis/Septicemia
  - Pressure ulcers stage 3-4
  - Progressive weight loss > 10% in past 6 months
  - Serum albumin < 2.5 gm/dl of body weight
  - Fever recurrent after antibiotics
  - Delirium
  - Recurrent aspiration pneumonia
Cardiopulmonary Disease
Heart Disease
1. Optimally treated for heart disease
2. Meets criteria for NYHA Class IV
3. Ejection fraction < 20% (helpful but not required)
4. Documentation of the following support hospice eligibility:
  - Treatment resistant symptomatic supraventricular or ventricular arrhythmias
  - History of cardiac arrest or resuscitation
  - History of unexplained syncope
  - Brain embolism or cardiac origin
  - Concomitant HIV disease
Lung Disease
1. Disabling dyspnea at rest, poorly responding to bronchodilators
2. Progressive pulmonary disease with increasing ER visits, physician office visits, or hospitalizations for pulmonary infections/respiratory failure
3. Hypoxemia at rest, on room air: oxygen saturation of 88%, p02 < 55 mg Hg, or pC02 > 50 mm Hg
4. Documentation of the following support hospice eligibility:
  - Unintentional progressive weight loss > 10% of body weight over prior 6 months
  - Resting tachycardia > 100/min.
Amyotrophic Lateral Sclerosis (ALS)
1. PPS < 40%
2. Body mass index below 22 kg/m²
3. Critically impaired respiratory function
4. Severe nutritional insufficiency as defined by dysphagia with progressive weight loss of at least 5% body weight with or without election of artificial feeding.
Renal Failure
1. Patient is not seeking renal transplant or dialysis to prolong life expectancy greater than 6 months.
2. Creatinine clearance < 10 cc/min (<15 cc/min for diabetics) or < 15 cc/min (< 20 cc/min for diabetics) with comorbidity of CHF
3. Serum creatinine > 8.0 mg/dl (6.0 mg/dl for diabetics)
Stroke/Coma
Stroke
1. PPS < 40%
2. Inability to maintain hydration and calorie intake with 1 of the following:
  - Weight loss > 7.5% in the past 3 months
  - Weight loss > 10% in the past 6 months
  - Serum albumin < 2.5 gm/dl
  - Pulmonary aspiration without effective response to speech therapy intervention
  - Inadequate caloric/fluid intake
  - Severe dysphagia (prevents life-sustaining nutrition)
Coma
1. On third day of coma, any 3 of the following:
  - Abnormal brain-stem response
  - Abssent verbal responses
  - Absent withdrawal response to pain
  - Serum creatinine > 1.5 mg/dl