Hospice Eligibility Requirements
Healthcare professionals rely on a combination of criteria and symptoms to determine whether it’s time for hospice. These can include:
- A terminal diagnosis with a prognosis of six months or less
- Frequent hospitalizations within the past six months
- Declining cognitive and functional abilities with a rating of 50-60% on the Palliative Performance Scale (PPS) or dependence on three of the six Activities of Daily Living (ADLs)
- Significant weight loss (more than a 10% loss of body weight within six months)
- Increasing fatigue that is affecting the patient’s ability to carry out daily functions
- Comorbidities that complicate the patient’s health
- Frequent falls that cause injuries
- Declined tolerance for physical activity and lack of mobility
To qualify for hospice care, the patient must meet at least two of the above criteria, as determined by the physician’s professional opinion. The patient’s physician can also help prepare patients for what to expect at the hospice so they and their families are confident in their decisions.
Paying for Hospice:
Insurance and Payment Options
Many families hesitate to explore hospice because they feel unsure about how care is paid for, and that financial uncertainty can add stress to an already emotional moment. Understanding what insurance covers can bring clarity and reassurance during a time when you need simplicity, not confusion.
Most families receive hospice services through Medicare, Medicaid, or private insurance plans. These programs typically cover essential hospice support, including nursing visits, medications related to comfort, medical equipment, and emotional and spiritual care. Some plans may have small copayments for certain medications or respite stays.
If you need guidance with hospice coverage or eligibility, call (737) 240-3003 to speak with a member of our care team.
If your loved one does not have active insurance, there may still be options available through Medicaid enrollment, veterans benefits, or community support programs. Our team can review your situation, and guide you through the next steps. Click below to learn more about hospice insurance and coverage options.
Common Disease-Specific Criteria
Some illnesses may come with their own eligibility requirements, which will be used to determine whether hospice care is necessary.
- ALS (Amyotrophic Lateral Sclerosis). ALS patients who have lost the ability to swallow or breathe on their own will qualify for hospice.
- Alzheimer’s and Dementia. Patients with Alzheimer’s and dementia who experience a sharp cognitive decline, have difficulty swallowing, or have been diagnosed with sepsis, will be eligible for hospice. Physicians will determine whether patients can perform at least two Activities of Daily Living (ADLs) to qualify for hospice care.
- Heart Disease. Heart disease exhibits many different symptoms, and things like shortness of breath, chest pain, and functional decline of cognitive abilities will qualify patients for hospice.
- Neurological Conditions. Patients suffering from diseases like MS, ALS, and Parkinson’s can enter hospice when they show limited mobility, increased pain, and functional impairments.
- Oncology. Cancer patients who are no longer receiving curative treatments and spend more than 50% of their waking hours in bed will be eligible for hospice care.
