Your Guide to Medicare Hospice Eligibility Criteria

The decision for an individual to enter hospice or palliative care must take into account many different things. Health condition, diagnosis, and similar medical decisions are essential, but insurance coverage matter, too. This guide to Medicare hospice eligibility for 2020 can help you or your loved ones make an informed decision about care going forward.

Medical Eligibility for Hospice

The general physician or specialists who care for the individual considering hospice or palliative care will help to decide about Medicare eligibility. There are set requirements, but most of them are subjective to some degree. They include the following:

The diagnosis must have a six month or less life expectancy. This assumes that the disease progresses normally and is not slowed down by medical treatments or drugs.

The patient was hospitalized frequently in the past six months and would benefit more from continual care at home or in a residential facility with a hospice team.

A marked decrease in healthy weight or increasing weakness, fatigue, and difficulties performing activities of daily living such as dressing themselves, bathing alone, walking, and more.

The cognitive decline also influences the decision to enter hospice care. When the patient loses thinking, reasoning, and mental functioning abilities, they may benefit from oversight.

Other Medicare hospice eligibility criteria include repeated infections, breakdown of skin and musculature, and other specific and obvious declines in condition or function.

Unique Situations for Specific Diseases

Although many people associate hospice and palliative care with the elderly, many diseases also contribute to its need. Medicare has established unique rules for a list of them.

AIDS: After an HIV and AIDS diagnosis, the patient must exhibit specific signs of weakness and wasting, blood counts below a certain level, weight loss, and other associated chronic symptoms.

Cancer: Late-stage, metastatic cancer diagnoses that cause the patient to decline in health despite medical treatment or therapy make them eligible for hospice care.

Cardiopulmonary Disease: A non-treatable decline that involves life expectancy less than six months can make palliative care the best choice for heart disease sufferers.

Stroke: Lack of mobility, function sufficient to perform daily living actions, and ability to care for themselves with associated health decline may make an individual eligible for hospice care.

COPD: Frequent emergency room visits, functional impairment, lack of appetite and sleep, mobility and strength issues, and continuous need for breathing treatments or oxygen point to palliative care is an option.

Dementia and Other Neurological Issues: While the criteria for each vary slightly, Medicare hospice eligibility involves the ability to care sufficiently for themselves, get around, speak, or otherwise perform daily living activities.

Kidney and Liver Disease: Medicare eligibility for hospice includes various blood chemistry levels, the expectation of fatality, and the inability to care for themselves.

Insurance Is Required for Palliative Care

The hospice system requires payment just as all other medical and healthcare services do. According to the above criteria, Medicare eligibility may not mean full coverage by this government system, so investigate your plan carefully. Medicare and private health insurance programs also work to get you or your loved one the hospice and palliative care they need from LifeChoice in Wheeling, Illinois.