Coverage of hospice care depends upon a physician’s certification that an individual’s life expectancy is six months or fewer if the illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, the Center for Medicare and Medicaid Services (CMS) has published medical criteria for determining prognosis of certain non-cancer diagnoses. These guidelines form a reasonable approach to the determination of life expectancy based on available research.
If a patient meets the medical criteria, they are, by definition, eligible to receive hospice services. Some patients may not meet the criteria, but may still be eligible for hospice care because of other co-morbidities or rapid functional decline. It is the physician’s clinical judgment regarding the normal course of the individual’s illness that determines a prognosis of six months or fewer.