The Hospice Guide
Who Qualifies for Hospice?
The Medicare rules for hospice eligibility, what the six-month prognosis means, benefit periods, and how to request a hospice evaluation.
To qualify for hospice under Medicare, a doctor must certify that the person is terminally ill, with a life expectancy of six months or less if the illness runs its normal course. The person must also choose comfort care instead of treatment meant to cure that illness.
The Medicare requirements
Under Original Medicare, a person can receive hospice care when all of these are true:
- They have Medicare Part A (hospital insurance).
- The hospice doctor and their regular doctor (if they have one) certify that they are terminally ill, with a life expectancy of six months or less.
- They accept comfort (palliative) care instead of care to cure the illness.
- They sign a hospice election statement choosing hospice care instead of other Medicare-covered treatment for the terminal illness. This must be signed before hospice services begin.
Medi-Cal and most private insurance plans use similar rules.
What “six months or less” really means
The six-month rule is a doctor’s best medical judgment, not a deadline. Nobody can predict exactly how long a person will live. Some people live longer than six months on hospice, and that is allowed.
Medicare covers hospice in benefit periods: two 90-day periods, followed by an unlimited number of 60-day periods. At the start of each period, the hospice doctor must recertify that the person is still terminally ill. Before the third benefit period (after about six months), a hospice doctor or nurse practitioner must also see the person in a face-to-face visit.
Signs doctors look at
There is no single test for hospice eligibility. Doctors look at the whole picture, which often includes:
- Frequent emergency room visits or hospital stays
- Steady decline in the ability to walk, eat, bathe or dress without help
- Unplanned weight loss or eating much less
- Spending most of the day in a bed or chair
- Symptoms such as pain or shortness of breath that are getting harder to control
- A decision to stop treatments that are no longer working or are causing more harm than benefit
Each diagnosis also has its own signs. See our guides on cancer, COPD, ALS and other common hospice diagnoses.
Diagnoses are not “allowed” or “not allowed”
Hospice is not limited to cancer. Any terminal illness can qualify, including dementia, heart failure, lung disease, kidney or liver failure, stroke and ALS. What matters is the doctor’s prognosis, not the name of the disease. Some vague labels, such as “old age” or “general decline,” are not accepted as a primary diagnosis on their own; the doctor must name the specific conditions causing the decline.
How to get an evaluation
- Talk with your loved one’s doctor and ask directly: “Would you be surprised if they died in the next six months?”
- Ask the doctor or hospital discharge planner for a hospice referral, or call a hospice yourself and request an evaluation.
- A hospice nurse or doctor will review medical records and usually visit to assess the person.
An evaluation does not commit you to anything. Be cautious of any hospice that pressures you to sign up, offers gifts, or tells you someone qualifies without a doctor’s review. See how to choose a hospice for red flags.
Sources
This guide is general information, not medical advice. Only a doctor can certify hospice eligibility.