Who is eligible for hospice care?
A common misconception about hospice is that it is a service provided only to cancer clients. The fact is we provide care to clients with any end stage diagnosis. Diagnoses include, but are not limited to:
- Metastatic Malignancies
- Heart Disease, including congestive heart failure
- Kidney Disease
- Liver Disease
- Lung Disease
- Stroke and/or Coma
- Neurological Diseases (Alzheimer's, Parkinson's, Dementia, etc.)
- Lou Gehrig's Disease (ALS)
- Failure of Multiple Organ Systems
- Failure to Thrive (most notably undesired weight loss)
- Senescence (the physical and mental conditions associated with advancing age)
- Debility Unspecified (meaning no specific disease or condition is causing the terminal status)
Is it true that you must have only six months to live to be eligible for the Medicare Hospice Benefit?
Another common, and unfortunate, misconception about hospice is that the use of hospice care somehow guarantees the patient has less than six months to live.
The short answer to this is no. The longer answer follows.
When Medicare developed the hospice eligibility guidelines used by Medicare/Medicaid hospice providers like us, it included the “six months to live” guideline.
However, because of confusion and concern in the medical community about the six months guideline, Medicare issued a policy letter to explain and clarify it. We have included an excerpt from that letter to help you understand Medicare’s philosophy on this issue. This philosophy is also used by Medicaid and generally by private insurers. Please note that we have added bold type and underlining to emphasize points we believe are very important.
In its letter to physicians, Medicare stated the following.
“Hospice care that is covered by Medicare is chosen for specified amounts of time known as election periods. Essentially, a physician may certify a patient for hospice care coverage for two initial 90-day election periods, followed by an unlimited number of 60-day election periods. Each election period requires that the physician certify a terminal illness.
Generally speaking, the hospice benefit is intended primarily for use by clients whose prognosis is terminal, with six months or less of life expectancy. The Medicare program recognizes that terminal illnesses do not have entirely predictable courses. Therefore, the benefit is available for extended periods of time beyond six months provided that proper certification is made at the start of each coverage period.
Recognizing that prognoses can be uncertain and may change, Medicare's benefit is not limited in terms of time. Hospice care is available as long as the patient's prognosis meets the law's six month test.
This test is a general one. As the governing statute says: The certification of terminal illness of an individual who elects hospice shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.
CMS recognizes that making medical prognostication of life expectancy is not always an exact science. Thus, physicians need not be concerned. There is no risk to a physician about certifying an individual for hospice care that he or she believes to be terminally ill.”
We believe Medicare makes it abundantly clear the six months guideline is just that…a general guideline rather than a fixed requirement.
When does hospice care become appropriate?
Hospice care becomes appropriate when an individual has a life-limiting illness or condition. The individual's primary physician and the hospice Medical Director will work together to make this medical determination. The individual and family then decide whether he or she wishes to enter the hospice care program.
Informal Hospice Eligibility Questionnaire
We have prepared the following brief questionnaire that can help you determine whether hospice care is right for you or your loved one. You or your loved one may be eligible for hospice care if you check 4 or more statements.
However, please remember that your primary physician and our Medical Director will make the final decision regarding eligibility.
Please check the following statements as they apply to you or your loved one to see if hospice care may be appropriate.
I have started feeling more tired and weak.
I experience shortness of breath, even when resting.
I spend most of the day in bed or in a chair.
I have noticed an increased weight loss in the past six months.
I make frequent phone calls to my physician.
I take medications to lessen physical pain.
I have fallen several times in the past six months.
I have made frequent trips to the emergency room in the past six months.
I need help from others with important daily activities.
(bathing, dressing, eating, cooking, walking, getting out of bed)
My doctor has told me my life expectancy is limited.
If you have checked 4 or more items on the questionnaire, you may want to begin your research into hospice care by seeking the opinion and advice of your or your loved one’s primary physician. If you do not have a primary physician, we can refer you to our Medical Director, who is a Doctor of Internal Medicine.
Assessment Tools Commonly Used by Physicians
We are providing these guides only as examples of some of the tools physicians use to assist in determining hospice eligibility. Your physician and our Medical Director will determine your or your loved one’s eligibility for hospice care based on some or all of these plus any other health factors that could affect eligibility.
The individual has a declining functional status as determined by either:
- a Karnofsky Performance Status Scale of 50% or less. (The Karnofsky Performance Status is an evaluation that assesses a person's ability to function independently. This scale follows below.)
- dependence in 3 out of 6 Activities of Daily Living (see the specific activities below)
- frequent hospitalizations
- frequent trips to the Emergency Room
- weight loss of 10% or more in the last 4 to 6 months
- serum Albumin less than 2.5 gm / dl. (Albumin is a component of protein and makes up one half of plasma protein.)
- the individual or legal representative (either medical representative and/or power of attorney) has elected palliative care rather than curative treatment
Karnofsky Performance Status Scale
The Karnofsky Performance Status scale is the most widely used measure of an individual’s functional or performance status and is one of a number of tools physicians may use to assist in determining hospice eligibility.
Activity and Evidence of Disease
An individual is not appropriate for hospice, if he or she meets at least 50% of the threshold criteria.
Normal; no complaints; no evidence of disease
Able to carry on normal activity; minor signs or symptoms of disease; easily reversible
Normal activity with effort; some signs or symptoms of disease progression
Cares for self. Unable to fully carry out normal activities of daily living or to do active work.
Requires occasional assistance, but is able to care for most of own home care needs.
Requires considerable assistance and frequent medical care
Disabled; requires special care and assistance; unable to care for self; disease progressing
Severely disabled; although death is not imminent
Very sick; active supportive treatment necessary
Moribund; fatal processes progressing rapidly
Functional Assessment Staging (FAST)
This scale is another example of a tool physicians may use to assist in determining hospice eligibility. It is used primarily for Alzheimer’s and related diseases. The FAST scale identifies progressive steps and sub-steps of functional decline. Generally, a prospective client must be at level 7 to be eligible for hospice care.
This test is used in conjunction with other symptoms the individual may have, such as specific dementia-related co-morbidities (e.g., aspiration, upper urinary tract infection, sepsis, multiple stage 3-4 ulcers, persistent fever and/or weight loss >10% within six months).
Identify the highest level of disability. (Where shown, an asterisk indicates determinations are to be scored primarily on the basis of information obtained from a knowledgeable informant.)
1. No difficulty either subjectively or objectively.
2. Complains of forgetting location of objects. Subjective work difficulties.
3. Decreased job functioning evident to co-workers. Difficulty in traveling to new locations.
Decreased organizational capacity. *
4. Decreased ability to perform complex task, (e.g., planning dinner for guests, handling personal finances,
such as forgetting to pay bills, difficulty marketing, etc.)
5. Requires assistance in choosing proper clothing to wear for the day, season or occasion,
(e.g. patient may wear the same clothing repeatedly, unless supervised. *
A. Improperly putting on clothes without assistance or cueing (e.g., may put street clothes on
overnight cloths, or put shoes on wrong feet, or have difficulty buttoning clothing)
(Occasionally or more frequently over the past weeks. *
B. Unable to bathe properly (e.g., difficulty adjusting bath-water temperature) (Occasionally or more
frequently over the past weeks. *
C. Inability to handle mechanics of toileting (e.g., forget to flush the toilet, does not wipe properly
or properly dispose of toilet tissue) (Occasionally or more frequently over the past weeks. *)
D. Urinary incontinence (Occasionally or more frequently over the past weeks. *
E. Fecal incontinence (Occasionally or more frequently over the past weeks. *
A. Ability to speak limited to approximately a half a dozen intelligible different words fewer,
in the course of an average day or in the course of an intensive interview.
B. Speech ability is limited to the use of a single intelligible word in an average day or in
the course of an intensive interview (the person may repeat the word over and over.)
C. Ambulatory ability is lost (cannot walk without personal assistance.)
D. Cannot sit up without assistance (e.g., the individual will fall over if there are no arm rests on the chair.)
E. Loss of ability to smile.
F. Loss of ability to hold up head independently.
Activities of Daily Living
Dependence on assistance for two or more activities of daily living (ADLs):
C. transfer (e.g., bed to wheelchair)
Local Condition Determinations (LCDs)
Although listed last, LCDs play a key role in process of determining eligibility for hospice care under Medicare and Medicaid. LCDs are important tools Medicare and Medicaid directs us to use when determining eligibility for hospice care.
However, we want to caution you, once again, that LCDs are only one of several tools physicians use to determine eligibility, so please don’t consider an LCD to be the final word on eligibility. Physicians consider the complete health status of the individual in all respects before certifying or denying eligibility for hospice care.
The simplest explanation of an LCD is that it is a decision by Medicare/Medicaid whether to provide hospice care for a particular illness or condition. In other words, it is a determination whether hospice care is reasonable and necessary.
Here is a sample of one LCD. Note we have included only a portion of the LCD here. For our purposes here, we have removed most of the “government speak”. Please keep in mind that it still is a document from a government agency and, therefore, may require that you read it more closely. We have highlighted several areas that might be of interest to you.
LCD ID Number L16343 Hospice Alzheimer's Disease & Related Disorders
A. Indications and Limitations of Coverage and/or Medical Necessity
Alzheimer’s disease and related disorders may support a prognosis of six months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of Alzheimer’s disease are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with Alzheimer’s disease are by definition distinct from the Alzheimer’s disease itself. Examples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Secondary conditions on the other hand are directly related to a primary condition. In the case of Alzheimer’s disease examples include delirium and pressure ulcers. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.
The Reisberg Functional Assessment Staging (FAST) Scale has been used for many years to describe Medicare beneficiaries with Alzheimer’s disease and a prognosis of six months or less. The FAST Scale is a 16-item scale designed to parallel the progressive activity limitations associated with Alzheimer’s disease. Stage 7 identifies the threshold of activity limitation that would support a six-month prognosis. The FAST Scale does not address the impact of comorbid and secondary conditions. These two variables are thus considered separately by this policy.
B. FAST Scale Items: (Please see the FAST Scale above.)
C. Comorbid Conditions:
The significance of a given comorbid condition is best described by defining the structural/functional impairments, together with any limitation in activity, related to the comorbid condition. For example a beneficiary with Alzheimer’s disease and clinically significant CHD or COPD would have specific impairments of cardiorespiratory function (e.g., dyspnea, orthopnea, wheezing, and chest pain) which may or may not respond/be amenable to treatment. The identified impairments in cardiorespiratory function would be associated with both specific structural impairments of the coronary arteries or bronchial tree and may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the Alzheimer’s disease (stage 7) and any comorbid condition should be such that most beneficiaries with Alzheimer’s disease and similar impairments would have a prognosis of six months or less.
D. Secondary Conditions:
Alzheimer’s disease may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments - together with any limitation in activity - related to the secondary condition. The occurrence of secondary conditions in beneficiaries with Alzheimer’s disease is facilitated by the presence of impairments in such body functions as mental functioning and movement functions. Such functional impairments contribute to the increased incidence of secondary conditions such as delirium and pressure ulcers observed in Medicare beneficiaries with Alzheimer’s disease. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond/be amenable to treatment. Ultimately, the combined effects of the Alzheimer’s disease (stage 7) and any secondary condition should be such that most beneficiaries with Alzheimer’s disease and similar impairments would have a prognosis of six months or less.
The documentation of structural/functional impairments and activity limitations facilitate the selection of intervention strategies (palliative vs. curative) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.
For Beneficiaries with Alzheimer’s Disease to be eligible for hospice the individual should have a FAST level of greater than or equal to 7 and specific comorbid or secondary conditions meeting the above criteria.
F. ICD-9 Codes that Support Medical Necessity
290.3 SENILE DEMENTIA WITH DELIRIUM
331.0 ALZHEIMER'S DISEASE
331.11 PICK'S DISEASE
331.2 SENILE DEGENERATION OF BRAIN
If you would like to see the entire list of hospice LCDs, you can go here. When you look at the list of LCDs, be sure to pick the ones having the word, hospice, in the title.
If you would like to know more about the LCD process in general, you can visit the Center for Medicare and Medicare Services here and click on Chapter 13. The “here” you will be visiting is the Medicare and Medicaid Services (CMS) Internet-Only Manual (IOM) Pub. 100-08, Program Integrity Manual, Chapter 13, Local Coverage Determinations. (We would like to say we’re making this title up but, unfortunately, we’re not.)
We hope we have not made the determination of eligibility process sound more complicated than it really is. In our experience, the process has been simple and straightforward in almost all of our admissions. In a few cases physicians have had to rely on more comprehensive and detailed assessments, but we have never experienced a situation where an individual was denied the Medicare Hospice Benefit when he or she was truly medically eligible for it.
Autumn Journey Hospice
5347 Spring Valley Road
Dallas, TX 75254