Navigating healthcare can be tricky, especially when a disease is no longer responding to curative treatments and hospice care is necessary. Hospice eligibility opens up a wide range of services and compassionate care at the end of life, meaning a timely referral is key to ensuring benefits are fully utilized.

Hospice Criteria

Hospice benefits are covered by Medicare, Medicaid, Veterans Affairs, and many private insurance companies at little to no cost to the patient. Hospice coverage includes palliative care (aka comfort care) like pain and symptom management, medical equipment, support services like mental and spiritual care, and regular visits from nurses, aides, and volunteers.

To qualify for hospice benefits, patients must meet the following criteria:

1) Two physicians certify a patient has a life expectancy of six months or less if the disease runs its normal course. While the timeline of diseases is unpredictable, patients may requalify for hospice every 60 days after the six-month period.

2) The patient accepts comfort care (palliative care) instead of care to cure the illness. 

Conditions & Diseases Eligible for Hospice Care

Hospice improves an individual’s quality of life for someone with a terminal or life-threatening illness, yet the average hospice period is 2.5 months, meaning patients may be missing out on months of beneficial care. It’s vital for hospice providers like Heart to Heart Hospice to help educate primary healthcare providers on important hospice assessment guidelines and the referral process.

Patients must first have a primary diagnosis that is terminal, such as heart failure or kidney disease, not just a failure to thrive or debility that may contribute to their decline. See a list of non-allowable primary diagnoses from the National Hospice and Palliative Care Organization. The NHPCO 2023 Facts and Figures show the most common primary diagnoses are cancer and Alzheimer’s/nervous system disorders/organic psychosis.

The following primary diseases, once deemed life-limiting and terminal, may mean an individual qualifies for hospice. These are taken from the Medicare Coverage Database; click for the full criteria.

ALS (Amyotrophic Lateral Sclerosis) / Lou Gehrig’s Disease 

Patients display both difficulty breathing and swallowing.

Alzheimer’s and Dementia

Stage seven or beyond in the Functional Assessment Staging Scale, with the following:

  • Unable to move, dress, or bathe without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • No consistently meaningful verbal communication.

Metastasized at presentation or progression from an earlier stage of disease to metastatic disease with either 1) a continued decline in spite of therapy or 2) the patient declines further disease directed therapy.

Heart Disease

The patient has been treated or is not a candidate for/declined heart surgery. They are New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest, plus contributing factors like history of cardiac arrest or unexplained syncope (loss of consciousness from falling blood pressure).

Stroke and Coma 

A Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) of 40% or less and the inability to maintain hydration and caloric intake with weight loss, history of pulmonary aspiration, or other factors.

Neurological Disease / Multiple Sclerosis / Parkinson’s Disease

Patient has critically impaired breathing with dyspnea at rest, rapid disease progression in speech, ambulation, diet, and recurrent life-threatening complications in the last 12 months.

Lung Disease / COPD

The patient displays disabling dyspnea at rest and progression of increased symptoms leading to hospitalizations, infections, or respiratory failure.

Kidney Disease / Renal Failure

The patient is not seeking or discontinuing dialysis or a renal transplant and displays low kidney function on creatinine clearance or serum creatinine diagnostic tests.

Liver Disease

The patient should show a) prolonged prothrombin time (blood clot) and b) end-stage liver disease with signs of ascites, hepatic encephalopathy, recurrent bleeding, or other symptoms.

Non-Disease Guidelines

After the principal hospice diagnosis, other clinical criteria may help patients qualify for hospice, outlined below (as given in this National Institutes of Health report):

A. Physiologic impairment of functional status as interpreted via the Karnofsky Performance Status or Palliative Performance Score of less than 70 percent.*

B. The individual needs assistance for greater than or equal to two activities of daily living (ADL): ambulation; transfer; dressing; feeding; continence; and bathing.*

*Both A and B must be met to qualify.

C. Other conditions (also called comorbidities): The presence of significant disease that may  contribute to a prognosis of six months or less survival should be considered:

  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure (CHF)
  • Ischemic heart disease
  • Diabetes mellitus
  • Neurologic disease (cerebrovascular accident, Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis)
  • Renal failure
  • Liver disease
  • Neoplasia
  • Acquired immune deficiency syndrome/HIV
  • Dementia
  • Refractory severe autoimmune disease (e.g., lupus or rheumatoid arthritis)
  • Recurrent sepsis