Medicare Hospice Benefit Certification Requirements

Hospice programs help terminally ill patients through their final days with services aimed at improving quality of life and comfort. Hospice-trained staff not only provide medical care aimed at alleviating pain or discomfort, but also address the emotional, spiritual and social needs of dying patients and those close to them. Medicare covers hospice care benefits through its hospital insurance program (Part A). Medicare patients must meet certification requirements qualify for hospice.

Terminal Illness

• To receive a Medicare hospice benefit, the patient must be terminally ill. Medicare standards say a person is terminally ill if his or her life expectancy is six months or less. This life expectancy is based on the prognosis that the person's illness or disease will run its natural course.

Physician's Approval

• A hospice medical director and the patient's attending physician must issue a written certification declaring that the patient is terminally ill. The written certification must include clinical findings and medical details that support the prognosis. If the hospice medical director is unavailable, the physician member of the hospice interdisciplinary group can take his/her place. The attending physician is a doctor of medicine or osteopathy identified by the patient during the election of hospice care. A nurse-practitioner may take the place of the attending physician.

Hospice Election

• The terminally ill person or a representative must elect a Medicare-approved hospice care provider by filing an election statement. Qualified persons can initially apply for 90-day coverage. After this initial application, they may apply for unlimited Medicare coverage. The Common Working File (CWF) receives and maintains this election in electronic format. After the processing of the initial election is completed, CWF will grant the beneficiary a hospice status. This status will end when the beneficiary dies or when CWF receives an election termination request.

Certification Period

• The initial certification process must be completed within two weeks prior to the election of hospice care. The hospice must have the written certification on file within two calendars days after the hospice benefit begins. If obtaining the written certification is not possible within this time period, then the patient can obtain a verbal certification. Medicare will cover only the expenses starting the day of the certification, and onward.