Diagnostic Eligibility Guidelines

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In the past, hospice eligibility was often defined as having a prognosis of “six months or less”. However, hospice providers and physicians were often frustrated by trying to make this very difficult, and somewhat arbitrary, determination.

In 2008, the Center for Medicare and Medicaid Services (CMS) developed guidelines outlining specific clinical standards that indicated such a prognosis for multiple diagnoses. These guidelines now serve as the standard for the medical determination of hospice eligibility.

CareFirst uses these guidelines to determine medical eligibility for hospice care. Physicians who cover patients on Hospice will be asked to use the guidelines, including signing them as certifying a patient’s prognosis, when their patients are admitted to hospice. The same guidelines will also be used when determining if patients continue to be eligible for hospice coverage over time.

Familiarity with these guidelines will help physicians determine which of their patients may be eligible for hospice care, or when it may be appropriate to start adapting care plans to maximize the benefit of palliative care.

CareFirst’s Medical Director is available to address any questions you may have at 607.962.3100, or to discuss eligibility for diagnoses not listed below.

Medicare Eligibility Guidelines:

  • Amyotrophic Lateral Sclerosis (ALS)
  • Breast Cancer
  • Dementia
  • Heart Disease
  • Liver Failure
  • Lung Cancer
  • Prostate Cancer
  • Pulmonary Disease
  • Renal Disease
  • Stroke
  • General Guidelines