How Does Insurance Decide When a Person Is Eligible for a Hospice?

According to the Horizon Hospice of Spokane, Medicare and Medicaid hospice service coverage is unusual in that hospice benefits are fully covered, meaning the patient is not expected to pay coinsurance. Private insurers establish guidelines for policyholders based on internal standards. However, since the federal government is the "single largest payer for health care services in the United States," policies adhered to by Medicare and Medicaid concerning hospice services are often the standards for private insurers. Horizon states that even though benefits vary among private insurers, some insurers follow Medicare guidelines. The policyholder should check the terms of private health insurance contracts for specifics.

Defining Hospice Patient

• The U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services states that there is no simple way to define the term "hospice patient" and that the term itself does not appear in the wording of federal laws on the books. The Centers for Medicare and Medicaid emphasizes that the certification necessary for a hospice patient to receive benefits is an agency requirement and that this certification does not apply to private insurers or to patients without health insurance.

Certification Requirements

• Federal legislation mandates that to meet eligibility requirements hospice care be available to those patients who request the service and are certified eligible by an attending physician prior to service being initiated. In other words, under Medicare regulations a patient must want hospice care to receive it. Should the patient be incapacitated, an authorized representative such as a health care advocate may request the service. Once the request is made, an attending physician must certify the patient as hospice eligible. Medicare defines an attending physician as "a doctor of medicine or osteopathy or a nurse practitioner and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care."

Standard Eligibility

• When an attending physician certifies an individual as being hospice eligible, the medical professional is attesting that the patient is terminally ill. Terminally ill, in this case, means the patient is not expected to live more than six months if the diagnosed illness continues on a "normal course." Under Medicare regulations, if a patient exceeds the life expectancy prognosis, benefits will not be terminated on that basis alone.

Re-certification

• A physician certification for hospice service typically lasts for 90 days, after which the patient must be re-certified to meet continuing eligibility requirements. Before a patient can be re-certified for a third time, the attending physician must meet with the patient face-to-face before attesting to continuing eligibility. Regardless of the physician, the hospice director, or the insurance case manager's opinion, the patient has the right to discontinue hospice service at any time by declaring their wishes in writing.