Hospice provides a valuable service to terminally ill patients and their families. It allows patients to be as comfortable as possible and provides emotional, spiritual and physical support during this challenging time. There are a few things that count towards a patient having hospice eligibility.
The Main Criteria For Hospice Eligibility
The main criteria for determining a person’s hospice eligibility are having a terminal illness and a life expectancy of six months or less should their disease run its expected course. This status must be certified by a doctor, and the medical director of the hospice must agree with the physician’s assessment.
Outlined below are three other situations that may precede a physician recommending that a patient enters hospice care.
The Patient’s Condition Does Not Improve
If a patient undergoes treatment but their condition does not improve, they do not feel better and their illness progresses to end-stage disease, hospice can help with comfort care.
The Objectives Of The Patient’s Care Have Changed
If a patient realizes that they are not improving and they no longer wish to receive curative treatment or spend time in a hospital, it may be time for hospice. In addition, patients who are growing anxious about the prospect of dying can find emotional and spiritual comfort from the services that hospice care provides.
The Patient Suffers An Acute Health Event
After a patient has been referred to hospice, a hospice nurse will carry out a health assessment to look for some of the common signs that hospice is appropriate. These include:
- Pain or emotional suffering
- Difficulty swallowing
- Recurring infections
- Increased visits to the emergency room or hospital with limited or no improvement
- Increases in fatigue and daytime sleeping
- An inability to carry out daily activities independently
- Weight loss of 10% during the past three to six months
- Confusion and cognitive impairment that is worsening
- Rapid progression of the disease despite treatment
A scale known as the Palliative Performance Scale is sometimes used to determine whether a patient’s functional status is declining.
Hospice Eligibility Requirements For Medicaid, Medicare, and Insurance
Hospice is covered by Medicaid, Medicare, and private insurance, and each source has its own set of eligibility requirements.
Medicaid Hospice Eligibility Requirements
Medicaid participants can receive hospice care when they have been diagnosed with a terminal illness and a prognosis of fewer than six months to live.
Eligibility requires certification by a physician, and the patient must agree to discontinue undergoing curative treatment if they are over the age of 21 and complete an election form. Hospice services are usually covered fully by Medicaid for patients and their families and can be provided wherever the patient is currently living.
Although patients are expected to live for six months or less when they are referred to hospice care, there may be cases where the patient lives longer than expected. Medicaid patients can receive an unlimited number of 60-day benefit periods following their initial six months in hospice as long as they are recertified as continuing to be terminally ill with a prognosis of six months or less to live.
Medicare Hospice Eligibility Requirements
To receive the Medicare Hospice benefit, patients must have Medicare Part A, a diagnosis of six months or less to live, and a desire to undergo comfort care instead of curative treatment.
After formally choosing to receive hospice care, the patient’s benefits are divided into benefit periods starting with two 90-day periods, followed by an unlimited number of 60-day benefit periods should they continue to meet the qualifications.
The Medicare hospice benefit can be received wherever the patient resides, but they may not receive concurrent enrollment in skilled nursing care and hospice for the same diagnosis.
Private Insurance Hospice Eligibility Requirements
Most patients use Medicaid or Medicare to cover their hospice services, but it is also possible to use private health insurance for hospice care. Whether it is purchased privately from a health insurance provider or the Affordable Care Act marketplace or it is provided by an employer or retirement program, most private insurance plans will cover
Although each company will have its own set of requirements that must be met before beginning hospice care, patients generally must have been diagnosed with a terminal illness and a life expectancy of fewer than six months and must stop curative treatment before beginning hospice.
Reach Out To The Compassionate Hospice Care Team
Dealing with a terminal illness and making decisions about care can be difficult for families. If you would like to find out more about how hospice care can help and whether or not your loved one meets the requirements, get in touch with the compassionate hospice care team at Harbor Light Hospice.