Hospice care can be of great help to patients struggling with chronic, life-limiting conditions, but how do you know if your loved one is eligible for it? Let’s take a look at how medical professionals determine hospice care eligibility, as well as how you can determine eligibility for Medicare’s hospice benefit.
Who Determines Hospice Care Eligibility?
A healthcare professional, usually a general physician, will be the first to determine if your loved one meets hospice care eligibility requirements. They’ll be the one to diagnose your loved one’s chronic condition as “life-limiting.” From there, they may provide a referral to a reputable hospice care provider in your area.
What Are the Typical Hospice Care Eligibility Requirements?
What key symptoms do doctors consider when determining hospice care eligibility? What constitutes a life-limiting condition? While these answers may vary from patient to patient and condition to condition, there are a few general signs they look out for, including:
- Declining functional capacity, which is often measured by dependence in at least three of the six main activities of daily living (ADLs): eating, bathing, dressing, transferring, toileting, and walking.
- Rapid weight loss, where “rapid” generally means at least a 10% loss in the last 4-6 months.
- Observable and documented deterioration of condition in the last 4-6 months, which could be seen in frequent hospitalizations, decreases in physical activity, decreases in cognitive function, and more.
- Recurrent infections, which can be difficult to treat and keep away.
A Few Condition-Specific Hospice Care Eligibility Requirements
Aside from the general signs and symptoms listed above, doctors often use condition-specific measurements to determine hospice care eligibility. Below, we’ll take a look at just three specific conditions, and what related symptoms may push doctors to make a hospice referral.
Cancer
Cancer is a disease in which abnormal cells divide and metastasize uncontrollably, destroying body tissue. There are many different forms of cancer — and while some can be treated with chemotherapy and radiation, others may not respond to treatment.
When a cure or long-term remission is out of reach, hospice care can help cancer patients manage their chronic symptoms and live more comfortably. Here are some of the hospice care eligibility requirements for those with cancer:
- Pathology reports reveal evidence of cancer malignancy or metastases
- Progression to a more advanced cancer stage
- Continued decline in health in spite of treatments, or declining further curative treatments
- Any secondary health conditions, such as COPD, CHF, liver disease, neurological disease, etc.
Dementia
Dementia is the loss of cognitive functioning to such an extent that it interferes with a person’s daily life and activities. Actions like processing, remembering, and reasoning could be affected. Similar to cancer, there are various types of dementia — but while some treatments can help slow down the progression of the disease, dementia cannot yet be cured.
When the symptoms of dementia advance, hospice care can help dementia patients live peacefully and take the responsibilities of care off their families’ shoulders. A few of the hospice care eligibility criteria for those with dementia include:
- Incontinence
- Limited Intelligible Speech
- Difficulty bearing weight
- Any secondary health conditions, such as COPD, CHF, liver disease, neurological disease, etc.
Cardiovascular Disease
Cardiovascular disease is a disease that affects the heart with diseased vessels, structural issues, and/or blood clots. Again, there are many types of cardiovascular disease — and while some can be treated and resolved, others grow to become unmanageable and life-limiting.
Cardiovascular disease can be painful and scary for many patients, especially if their condition advances. Hospice care can help them manage their chronic pain and conditions, allowing them the comfort care they need. Here are some of the hospice care eligibility requirements for those with cardiovascular disease:
- Treatment with diuretics and vasodilators didn’t provide sufficient results
- Angina pectoris (chest pain) that’s resistant to standard nitrate therapy
- Not a candidate for (or declines) invasive heart surgery or procedure
- Any secondary health conditions, such as COPD, CHF, liver disease, neurological disease, etc.
How to Determine Medicare Eligibility for Hospice Care
In order for Medicare to cover 100% of your loved one’s hospice care expenses, they must meet the following requirements:
- Your loved one is 65 years old, or younger than 65 with a disability
- Your loved one is eligible for Medicare Part A benefits
- Your loved one’s doctor and hospice provider certify there is a life-limiting condition
- Your loved one signs a statement electing hospice care instead of other Medicare-covered treatments
Once determined eligible for the Medicare hospice benefit, your loved one will receive coverage for all hospice care expenses, with the exception of a possible $5 copayment for prescription drugs. This coverage does not include any room and board at nursing homes or specialized healthcare facilities if your loved one stays in one.
Caring for a loved one with a chronic condition, but not sure if they meet hospice eligibility requirements? We can help. It’s our top priority to provide your loved one with the best comfort care possible, which also means we’re committed to guiding you and your family through difficult decisions and answering any questions you have throughout the hospice process. Don’t hesitate to call us at CALL BUTTON (616) 258-2680 or contact us online.