Determining Hospice Eligibility

CMS Guidelines for Providers

Deciding when to refer a patient for hospice care is an essential step in providing them with the best possible care during the final stages of life. The Centers for Medicare & Medicaid Services (CMS) have provided guidelines to help you make these important decisions. This resource will take you through the eligibility criteria, covering both general requirements and disease-specific indicators, so you can ensure your patients get the care they need.

General Eligibility Requirements

To qualify for hospice care under Medicare and Medicaid, a patient should meet the following criteria:

The patient has a life-limiting condition, with a prognosis of six months or less if the illness follows its expected course.
The patient and/or family have been informed of this condition and have decided to proceed with comfort care rather than curative treatments.
The patient must demonstrate at least one of the following:
- A. Documented evidence of clinical decline, which can include:
  - Progression of the primary disease as documented by physician assessment, laboratory results, or other studies.
  - Multiple inpatient hospitalizations or emergency department visits over the past six months.
  - A decline in functional status, often measured by a Palliative Performance Scale (PPS) score of 50% OR dependence in at least three of six Activities of Daily Living (feeding, ambulation, continence, transfer, bathing, and dressing), as shown below:

%	Ambulation	Activity / Evidence of Disease	Self-Care	Intake	Conscious Level
100	Full	Normal Activity / No Evidence of Disease	Full	Normal	Full
90	Full	Normal Activity / Some Evidence of Disease	Full	Normal	Full
80	Full	Normal or Reduced	Full	Normal or Reduced	Full
70	Reduced	Unable Normal Job / Work / Some Evidence of Disease	Full	Normal or Reduced	Full
60	Reduced	Unable Hobby / House Work / Significant Disease	Occasional Assistance Required	Normal or Reduced	Full
50	Mainly Sit/Lie	Unable to Do Any Work / Extensive Disease	Considerable Assistance Required	Normal or Reduced	Full (With or Without Confusion)
40	Mainly in Bed	Unable to Do Any Work / Extensive Disease	Mainly Assistance	Normal or Reduced	Full or Drowsy (With or Without Confusion)
30	Totally Bed Bound	Unable to Do Any Work / Extensive Disease	Total Care	Normal or Reduced	Full or Drowsy (With or Without Confusion)
20	Totally Bed Bound	Unable to Do Any Work / Extensive Disease	Total Care	Minimal sips	Full or Drowsy (With or Without Confusion)
10	Totally Bed Bound	Unable to Do Any Work / Extensive Disease	Total Care	Mount care only	Drowsy or Coma
0	Death

B. Signs of nutritional decline, such as:
- Unintentional weight loss of more than 10% over the past six months.
  - Serum albumin of less than 2.5 g/dL (though this should not be used as the sole indicator).

While these general guidelines are helpful, each patient's situation is unique, and your clinical judgment is invaluable in this process. Saint Agnes Home Health and Hospice’s hospice experts are available to help you determine if your patient qualifies for hospice care. We encourage you to contact us with any questions or for further support.

Disease-Specific Guidelines

In addition to general eligibility criteria, CMS provides disease-specific guidelines to help clarify eligibility for common life-limiting conditions:

Other Considerations for Providers

While hospice care is intended for patients whose expected prognosis is six months or less, patients sometimes live beyond this period. If you believe the patient still has a life expectancy of six months or less, you can recertify their prognosis, allowing them to continue receiving hospice services.
Patients may choose to end hospice care at any time if their condition improves or if they decide to pursue curative treatment. They may also elect to use hospice services later if they become eligible again.

Helpful Resources

Helping patients get the right care at the right time is crucial, especially as they near the end of life. By combining your clinical expertise with a clear understanding of CMS hospice eligibility criteria, you can guide your patients and their families through a smooth transition to the comfort-focused, compassionate care they need.

At Saint Agnes Home Health and Hospice, we are here to support you and your patients. Whether you have questions or need assistance with a referral, our team is always ready to help. Together, we can make sure your patients get the care they deserve when they need it most.