Eligibility and Reimbursement for Services
Medicare, MediCal and most private insurance plans have a hospice benefit component that covers the costs associated with hospice care.
Beneficiaries who elect the Medicare or MediCal hospice benefit agree to forego curative treatment for their terminal condition. For conditions unrelated to their terminal diagnosis, Medicare and other payors continue to cover items and services outside of hospice.
Hospice Eligibility Guidelines
The first consideration is evaluating whether a patient has explored the options of curative treatment and prefers to be clinically managed with palliative treatments. In addition, the patient will have one or more of the following indicators:
* Loss of function/physical decline
* Increase or recent hospitalizations
* Increasing dependence in most activities of daily living
* Weight loss
* Discussion with attending physician regarding the transition from curative treatment to palliative treatment
A physician must certify that the patient’s prognosis is approximately six months or less if the disease runs it’s normal course. Hospice care can be extended beyond six months as long as the patient continues meeting eligibility criteria.
A Registered Nurse Case Manager if available 24 hours a day/7 days a week to discuss eligibility and to make home visits to assess appropriateness for hospice care.