Hospice Eligibility Criteria: Who is Eligible for Hospice Care?
To qualify for hospice care, a patient must meet the hospice eligibility requirements established by the U.S. Centers for Medicare & Medicaid Services. While no specific number of symptoms or diagnosis establishes eligibility, a combination of factors may determine that a patient is suitable for end-of-life care. Use the following guidelines can to assess whether a patient’s condition is, or will soon become, appropriate for a hospital referral.
Hospice eligibility requirements:
While there is no one diagnosis that qualifies a patient for hospice, a combination of symptoms can qualify a patient for end-of-life care. Consider the following criteria to determine if a patient is eligible for a hospice referral:
- Diagnosis of a terminal illness with a prognosis of six months or less based on the natural progression of the disease
- Frequent hospitalizations in the past six months
- Significant weight loss, accounting for factors such as edema, or an alteration in nutritional status (e.g., more than 10% loss of body weight over the past 4-6 months)
- Increasing weakness or fatigue that impacts daily functioning
- Declining cognitive and functional abilities, such as a Palliative Performance Scale (PPS) rating of 50-60% or dependence on others for at least three of six Activities of Daily Living (ADLs), including eating, bathing, dressing, toileting, transferring/walking, and continence
- Other comorbid conditions that further complicate the patient’s overall health
When is it time for hospice?
Curious about when hospice care might be the right choice for you or a loved one? Learn more about the signs that indicate it may be time for hospice care, and how it can provide comfort and support during the end-of-life journey.
Disease-specific requirements for hospice care.
ALS (Amyotrophic Lateral Sclerosis)
ALS patients may meet hospice admission criteria when they have lost the ability to breathe or swallow effectively, or when their functional decline becomes severe.
Cancer
Patients with metastatic cancer who experience a decline in condition despite treatment and are no longer receiving curative therapies may be eligible for hospice care.
Cerebral Vascular Accident (CVA) / Stroke
Stroke patients may qualify for hospice if they have experienced a significant decline in functional abilities, recurrent complications, and are primarily confined to bed or a chair.
Congestive Heart Failure / Cardiopulmonary Disease
Patients with heart failure or cardiopulmonary disease may be ready for hospice when they show structural or functional impairments, poor response to diuretics or vasodilators, and a general decline in endurance.
COPD / Cardiopulmonary Disease
Hospice eligibility for COPD patients includes severe respiratory symptoms, frequent exacerbations, and shortness of breath or chest tightness, even with minimal activity.
Dementia
Patients with dementia or Alzheimer’s may meet hospice eligibility criteria when they experience significant cognitive decline, difficulty swallowing, or are diagnosed with pneumonia or sepsis.
HIV/AIDS
Patients with HIV/AIDS may qualify for hospice if they have low CD4 counts, high viral loads, generalized weakness, and frequent infections, indicating a significant decline in their immune system.
Liver Disease
Liver disease patients may meet hospice eligibility requirements when they experience persistent symptoms such as recurrent variceal hemorrhages, hepatic encephalopathy, or peritonitis, signaling the advanced stages of hepatic failure.
Neurological Conditions
Patients with neurological diseases like Parkinson’s, MS, ALS, or Huntington’s disease may be ready for hospice when they exhibit severe structural or functional impairments, limited mobility, and increased pain or discomfort.
Renal Disease
End-stage renal disease patients who opt to discontinue or forgo dialysis, and experience a significant decline in kidney function and overall health, may qualify for hospice care.
Sepsis
Sepsis may admit a patient for hospice care when it occurs alongside end-stage diseases like heart failure, COPD, or liver disease, especially when recurrent infections or sepsis episodes contribute to a rapid overall decline in health.
Insurance requirements for hospice.
Generally, insurance requires a prognosis of six months or less and certification of terminal illness by a physician. View various insurance program’s hospice eligibility criteria:
Benefits of hospice care.
Patients benefit from hospice by receiving comprehensive care focused on comfort, symptom management, and emotional support during their end-of-life journey. If you’re unsure whether hospice care is the right choice, take a hospice quiz to help assess your situation.
If you still have doubt about whether the requirements for hospice care have been met, please contact us 24/7 at 855-327-4677 or use the Help Bar above for a hospice consultation.