Live Comfortably - January 31, 2025

Who is Eligible for Hospice Care?

by Kathie Miller

Considering hospice care for yourself or a loved one is never easy. It can feel emotionally challenging and complicated, but it’s also an incredibly important choice to make. Hospice care can profoundly improve the quality of life for both patients and their families, and it’s critical to begin the service as soon as it’s deemed necessary. Once started, hospice patients will receive 24/7 access to our nursing and physician services, social work resources, bereavement support, chaplaincy, volunteers, aides, durable medical equipment, and medication.

This article will cover the eligibility conditions and qualifications for hospice care services, but please do not hesitate to reach out to the Goodwin Hospice team with any questions at 703.578.7108 or HospiceReferrals@GoodwinLiving.org.

The 3 Primary Eligibility Conditions

Hospice care is an insurance benefit, so it comes with specific qualifications to ensure care is provided to those who need it. Fortunately, these criteria for hospice are generally straightforward, but we’ll expand more on each specifically below:

1. Certification of a terminal illness
2. A life expectancy of six (6) months or fewer 
3. The patient’s choice to seek care that improves their comfort rather than curative treatment 

1. Certification of a Terminal Illness

The first hospice qualification is the diagnosis and certification of a terminal illness by the patient’s physician or medical provider. The certification is shared with the chosen hospice provider, who then works with the patient’s insurance company to process. Acquiring the certification and having insurance providers process everything generally takes a few days to a week, ensuring care can begin as soon as possible.

2. Life Expectancy of Six Months or Fewer

The second hospice requirement is the diagnosis and certification of a life-limiting condition with a life expectancy of six (6) months or fewer based on the natural course of the disease by the patient’s physician or medical provider. Though different conditions and diseases have different requirements, some typical signs that may qualify patients include but are not limited to:

• Frequent hospitalizations in the past six months
• Significant weight loss, decreasing appetite, or trouble swallowing
• Insufficient hydration or nutrition
• Changes in cognitive and functional abilities
• Compromised Activities of Daily Living (ADLs)  like eating, bathing, or walking
• Inability to complete daily tasks, like eating, bathing, or walking
• Increasing weakness and fatigue
• Recurring infections or increasing pain

For a more detailed set of indicators of when to consider hospice care, read our blog: When Is Hospice Recommended?

3. Choosing Comfort Care vs. Curative Treatment

The third requirement for hospice care is the election of the patient to seek palliative care – care that focuses on improving quality of life and relieving pain rather than prolonging life. If the patient is unable to communicate or make decisions over their treatment, a medical power of attorney (POA) may elect on their behalf.

Do Eligibility Requirements Differ Based on Insurance?

From Medicare to Medicaid to private insurance and self-pay options, the eligibility requirements for hospice care may vary from plan to plan and state to state. Be sure to verify your or your loved one’s coverage to know what’s required for eligibility.

Medicare Hospice Coverage

Medicare is a federal health insurance program for people 65 and older, as well as younger individuals with qualifying disabilities. Part A of Medicare includes coverage for hospice care.

The Medicare hospice benefit provides quality end-of-life care for terminally ill patients. To qualify, patients must meet the following Medicare hospice eligibility criteria:

• Medicare Part A coverage
• A diagnosis of six months or fewer to live
• A desire to pursue comfort care over curative treatment

Medicaid Hospice Coverage

Medicaid, a federal and state-funded program, offers free or low-cost health insurance to low-income individuals. Most states provide hospice care under Medicaid for patients with a terminal illness and a prognosis of six months or less to live.

While eligibility criteria vary slightly by state, common requirements include:

• Certification of terminal illness by the patient’s physician
• Completion of an election form agreeing to hospice care
• Agreement to discontinue curative treatment (unless under 21 years old)
• Physician confirmation of reduced life expectancy with each eligibility certification

Private Insurance Coverage

While a majority of patients use Medicare or Medicaid for coverage of hospice services, some patients opt for private health insurance. These insurance plans shield patients and their families from paying the full cost of hospice services. While these plans generally cover the full cost of care, each health insurance company may have their own conditions patients must meet before they qualify for hospice — so it’s best to check with your respective insurance provider.

No Insurance (Self-pay)

Hospice providers may accept private payment, also known as “self-pay,” which can be an option for patients without healthcare coverage.

Sometimes a patient who needs hospice care has no way to pay for it. Many hospice providers have specialists who help patients who are medically eligible for hospice but don’t have insurance or the resources to pay for end-of-life care, in addition to some charitable organizations. 

What Services Will Qualifying Patients Receive?

At Goodwin Hospice, we offer comprehensive end-of-life care that integrates medical care with spiritual and other care services to meet your personal needs. Whether it’s at the comfort of your home, a senior living community or a healthcare facility, our services include 24/7 access to nursing and physician services, social work resources, bereavement support, chaplaincy, volunteers, aides, durable medical equipment, and medication. 

Goodwin Hospice also includes additional complimentary services that go beyond what is covered by insurance, such as massage therapy, a volunteer choir and end-of-life doulas.

What If the Patient Needs Care for Longer Than 6 Months?

Doctors can’t predict how an illness will progress, so a six-month prognosis might extend beyond that timeframe. Hospice care is designed with flexibility to accommodate this uncertainty.

Hospice care typically consists of two 90-day periods, followed by unlimited 60-day periods. After each period, a doctor reassesses the patient’s condition to decide if care should continue. To avoid gaps in care, start the reapplication process ahead of time to ensure approval before the next period begins.

Can Hospice Eligibility Be Reversed?

Hospice care is voluntary, and patients (or their POA) can choose to end it at any time. If a patient feels the care no longer suits their needs or decides to explore other treatment options, they are free to stop hospice services whenever they wish.

Revoking hospice care is a simple process that relies on clear communication between the patient, their family and the hospice care team. If a patient decides to discontinue hospice services, the hospice team works with them to ensure a seamless transition. This includes coordinating with other healthcare providers, arranging for required treatments or medications, and offering emotional support throughout the process.

How Do I Start the Hospice Care Qualifications Process?

To apply for hospice care, patients or family members can contact a hospice provider directly or ask the patient’s doctor for a referral. The process typically includes a qualifying medical evaluation to confirm eligibility and discussions with the hospice team to create a care plan.

How to Choose the Right Hospice Care Service Provider

It might feel overwhelming to find the right, high-quality hospice provider, especially when it’s already a challenging subject. Here are a few hospice guidelines to consider when evaluating options for providers. Rest assured, Goodwin Hospice checks all these boxes.

• Certifications: Verify the provider is Medicare-certified and licensed in your state.
• Coverage: Check if your provider accepts coverage with your plan, whether it’s through Medicare, Medicaid, or a private insurance plan.
• Availability: Ensure 24/7 support is available for emergencies or questions.
• Home Care: Explore if it’s offered. We believe everyone deserves end-of-life care in the comfort of their own home, surrounded by loved ones.
• Qualifications: Check the experience and credentials of the care team, including doctors, nurses, and counselors. Awards, reviews, and referrals can also indicate high-quality providers.
• Services: When choosing a provider, ask about the types of services provided by the hospice to ensure you’ll have the coverage you need when it matters most.

For a more in-depth look at what services are typically offered by hospice providers, read our blog: What Services Are Included in Hospice Care?

Common Misconceptions About Hospice Care

To help foster better understanding of hospice care and what it can do for you and your loved ones, we want to address some of the most common hospice misconceptions.

1. Hospice is a place you go to die. To all of us at Goodwin Living, hospice is not a place. It’s a philosophy of care. A primary goal is to help patients live out their days where and how they wish. 
2. Hospice is only for the final days or weeks. Patients may become eligible for hospice care once a physician has determined their life expectancy is six months or fewer. Studies suggest that beginning hospice earlier in the end-of-life process can lead to better experiences. 
3. You need a doctor’s referral before you consider hospice. You or your loved ones can call hospice and request a consultation without a physician’s referral. It’s your choice to pursue this specialized care, though being admitted formally to hospice requires certification of a terminal diagnosis.
4. Hospice care is just about the patient. Loved ones often find themselves in the role of caregivers when someone has a terminal illness. Hospice care supports the patient and their loved ones during the process. 
5. Hospice care is not covered by insurance. Medicare and most insurance providers offer coverage for hospice care. Coverage includes paying for medication, medical equipment, medical supplies, and the care team. Another consideration for patients in Northern Virginia is that Goodwin Hospice does not turn away patients who lack financial resources. This is one of many advantages to our non-profit hospice care model.
6. What’s the point of hospice if I’m dying anyway? At Goodwin Hospice, we strive to deliver hope. We understand that a terminal diagnosis is difficult news to process. We take time to ask “what is most important to you” as you live your final days. Our goal is your goal and we truly believe you can still live the fullest possible life in the time that remains.

For more on dispelling common misconceptions surrounding hospice, read our blog: Fostering an Understanding of Hospice Care.

Why You Should Consider Goodwin Hospice

When it comes to hospice care services, Goodwin Hospice is the premier choice to serve as your provider. Our mission is to provide simply the highest-quality, patient-centered care to our hospice patients and their loved ones. And it shows — Goodwin Hospice received a four-star rating from Medicare.gov in the February 2024 quarterly Care Compare Care Quality Report. As the highest rating in the hospice category for Northern Virginia, we’re proud to offer this level of end-of-life care. We’ve brought it to our residents for more than 20 years, and we have offered it to our community, including Alexandria, Arlington, and Falls Church, since 2016.

Goodwin Hospice is able to deliver the most compassionate care available because of our top-ranked team of Medicare-certified hospice care providers with more than 50 years of experience. From physicians, nurse practitioners, and registered nurses to licensed clinical social workers, spiritual counselors and bereavement counselors, our team delivers comprehensive care when you and your loved ones need it most. And we couldn’t do it without our wide network of dedicated hospice aides and volunteers to support the rest of the team. It’s a synergy that’s unmatched, and patients can tell they’re receiving only the best in hospice care.

Because Goodwin Hospice believes everyone has the right to die with comfort and dignity, we go above and beyond to deliver this exceptional end-of-life care. In addition to pain management and symptom control, personal care, social work services, counseling, and spiritual support, and 24/7 on-call nursing support, Goodwin Hospice offers several complimentary additional services. These include our compassionate visitor volunteers, pet companion, end-of-life doulas, end-of-life massage therapists, and visits from Threshold Choir singers. Hospice services include 13 months of bereavement following the loss of a loved one. This benefit is structured in order to provide support through the anniversary of the person’s death.

Contact Goodwin Hospice

Questions? We’re happy to help at any time. Feel free to contact us at 703.578.7108 or HospiceReferrals@GoodwinLiving.org to ask any questions or get more details about Goodwin Hospice.