Navigating Hospice Criteria for Medicare Eligibility

Currently, the vast majority of hospice patients are covered by Medicare and Medicaid. In order to qualify for hospice treatment through these programs you must meet a minimum set of hospice criteria set forth by the U.S. Centers for Medicare & Medicaid Services. These criteria are broken up into general s and disease-specific guidelines to better determine whether or not hospice care is appropriate.

General Hospice Criteria

The first general hospice criteria is that the patient must have been diagnosed with a known life-limiting illness that is likely to be terminal within six months. Other criteria includes frequent hospitalizations and recurring infections. Hospice is often recommended for those who are unable to manage the Activities of Daily Living such as eating on their own, using the restroom, bathing, etc. Other reasonable criteria are a general deterioration of mental ability, significant and ongoing loss of weight, and increasing fatigue. A patient may qualify by meeting some or all of these criteria.

Diagnosis Specific Criteria

Due to the frequency of some diagnoses and the wide range of symptoms associated with these illnesses, there are a number of criteria laid out for handling cases of AIDS, dementia, cancer, Parkinson’s, Stroke and more. These specific criteria are designed to help families make an educated decision based upon the progress of the illness itself and symptoms that are directly related to the diagnosis. The dementia criteria includes a provision for patients whose communication deteriorates to less than six words per day and are no longer able to smile. Meanwhile, those with liver disease should be looking for signs of muscle wasting and malnutrition. Liver disease patients also have specific criteria for organ transplants as well.

Special consideration is given to patients who are diagnosed with two or more life-limiting illnesses which may further complicate their treatment. It is also important to note that Medicare has not published an exhaustive list of illnesses. Rather they have focused on creating umbrella guidelines for illnesses that are most frequently diagnosed without going into the specifics of each individual type of cancer or dementia.

The best way to determine whether or not your loved one qualifies for hospice is to speak with an expert in the hospice industry.Contact Wings of Hope at 602-971-0304 for help with sorting through the various hospice criteria for Medicare and answer any questions you may have. Our patient representatives can provide you with specific information based on your diagnosis to help you determine eligibility.