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Hospice eligibility requirements

In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and certified as being terminally ill by a physician and having a prognosis of 6 months or less if the disease runs its normal course.  42 CFR 418.20 § 418.20   Eligibility requirements.             

  • Hospice Pre-Election Evaluation and Counseling Services (CR 3585) - Medicare allows for a one-time visit by a physician who is either the medical director of or employee of a hospice agency to:
  • evaluate the individual’s need for pain and symptom management
  • counsel the individual regarding hospice and other care options
  • advise the individual regarding advanced care planning

In order to be eligible to receive this service, a beneficiary must:

  • be determined to have a terminal illness (which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course;
  • not have made a hospice election, and
  • not previously received the pre-election hospice services

Eligibility and the Local Coverage Determinations (LCDs)

The LCDs for the hospice’s geographic area are used as guidelines to help a physician determine hospice eligibility.  The LCDs are not regulations and should not be used exclusively to determine or provide evidence of hospice eligibility.  Certification or recertification is based upon a physician’s clinical judgment, and is not an exact science.  Congress made this clear in Section 322 of the Benefits Improvement and Protection Act of 2000 (BIPA), which says that the hospice certification of terminal illness “shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness.”