Hospice Eligibility Criteria: Building a Certification of Terminal Illness That Survives Review

The referral says "end-stage heart failure, family wants hospice." The patient is clearly very sick. The admitting nurse writes "appropriate for hospice," the medical director signs, and a year later a reviewer reads the record and finds a diagnosis, a signature and no evidence of decline. The patient was dying. The chart did not say why anyone thought so.

Hospice eligibility criteria are simple to state and demanding to document. This guide sets out the legal test, the certification and narrative rules in 42 CFR 418.22, the clinical indicators MACs use in review, a worksheet for intake and admission, and the recertification points where eligibility is usually lost.

The Legal Test Behind Hospice Eligibility Criteria

Under 42 CFR 418.20, a person is eligible to elect Medicare hospice care if they are entitled to Part A and certified as terminally ill under 418.22. The Medicare Benefit Policy Manual, Chapter 9, section 10 defines terminally ill as a medical prognosis of a life expectancy of 6 months or less if the illness runs its normal course.

The manual adds three points intake teams should know:

• In deciding to certify, the hospice medical director must consider at least the diagnosis of the terminal condition, other health conditions whether related or unrelated, and current clinically relevant information supporting all diagnoses.
• Only a medical doctor or doctor of osteopathy can certify or recertify terminal illness. Nurse practitioners and physician assistants cannot, even when one is the patient's attending.
• Predicting life expectancy is not exact, and living longer than expected is not, by itself, a reason to end benefits.

Coverage runs in benefit periods: two 90-day periods followed by an unlimited number of 60-day periods, each needing its own certification.

What a Certification Must Contain

42 CFR 418.22 sets the content and timing. A complete certification has:

1. 1.The prognosis statement: life expectancy of 6 months or less if the terminal illness runs its normal course.
2. 2.Supporting clinical information filed with the certification in the medical record. It may be given verbally at first but must be documented and included in the eligibility assessment.
3. 3.A brief narrative by the physician explaining the clinical findings that support the prognosis, on the form or as an addendum.
4. 4.Signatures and dates of the physician or physicians, with the benefit period dates the certification covers.

Who certifies: for the initial 90-day period, the hospice medical director, physician designee or physician member of the interdisciplinary group, and the attending physician if there is one. For later periods, one hospice physician is enough.

When: if the written certification cannot be obtained within 2 calendar days after a period begins, the hospice must get an oral certification within 2 calendar days, and the written certification before submitting a claim. Certifications may be completed up to 15 calendar days before the election's effective date, and recertifications up to 15 days before the next period starts.

The Narrative Is Where Certifications Fail

The narrative rules are specific. If the narrative is on the form, it sits immediately above the physician's signature. If it is an addendum, the physician signs the form and again immediately after the narrative. Directly above the signature, a statement must attest that the physician composed the narrative based on a review of the record or an examination of the patient. Most important, the narrative must reflect the patient's individual circumstances and cannot contain check boxes or standard language used for all patients. The manual adds that the physician may dictate it, but must synthesize the patient's information to compose it.

A template sentence such as "patient has end-stage disease with poor prognosis" fails that test however well it reads. A narrative that holds up names this patient's numbers: weight, function, symptoms, hospitalizations and how each has changed.

The Clinical Indicators Reviewers Use

MACs publish local coverage determinations that describe how they review terminal status. CGS's LCD L34538, Hospice Determining Terminal Status, current version effective August 6, 2026, is one example; other MACs publish their own versions, so check yours. The LCD gives two routes:

• Part I, decline in clinical status. Documented, non-reversible decline, with baseline and follow-up values. Indicators include recurrent or intractable infections; progressive inanition such as weight loss not due to reversible causes, falling serum albumin, or dysphagia with aspiration or decreasing intake; worsening symptoms such as dyspnea with rising respiratory rate or pain needing increasing analgesic doses; signs such as systolic blood pressure below 90, ascites or edema; decline in Karnofsky Performance Status or Palliative Performance Scale from below 70%; increasing emergency visits or hospitalizations for the hospice diagnosis; and progressive stage 3 to 4 pressure ulcers despite optimal care. No set number is required.
• Part II, baseline plus disease-specific guidelines. A KPS or PPS below 70% and dependence on assistance for two or more activities of daily living, combined with the disease-specific guideline in the LCD's appendix. The LCD says the baseline guidelines do not qualify a patient on their own.

The LCD also lists comorbidities that should be considered, such as COPD, heart failure, diabetes, renal failure and dementia. And it states that patients who do not meet the guidelines may still have a prognosis of 6 months or less, and coverage may be approved if documentation of other supporting clinical factors is provided. The guidelines are evidence, not a gate.

A Worked Example: Heart Disease

Return to the opening referral. The LCD's heart disease guideline says items 1 and 2 should be present, with item 3 factors adding support:

1. 1.The patient is or has been optimally treated for heart disease, or is not a candidate for a procedure, or has declined one.
2. 2.The patient is NYHA Class IV, unable to carry on any physical activity without discomfort, with symptoms possibly present at rest. An ejection fraction of 20% or less may document significant heart failure but is not required if not already available.
3. 3.Supporting factors such as treatment-resistant arrhythmias, history of cardiac arrest, unexplained syncope or cardiac-origin brain embolism.

An intake record that will hold up captures: medications and why any standard therapy is not used; the cardiologist's note on procedures; a dated description of what the patient can and cannot do; the most recent echocardiogram if one exists; three hospitalizations in four months with dates; weight trend; PPS on admission. The physician's narrative then summarizes those facts in two or three sentences of their own words.

An Admission Evidence Worksheet

Build these fields into the referral and admission record:

1. 1.Terminal diagnosis and related conditions, with source documents and dates.
2. 2.Baseline function: PPS or KPS, ADL dependencies by name, with date and assessor.
3. 3.Decline evidence: at least two dated data points for each indicator used, such as weight, albumin, PPS, hospital visits.
4. 4.Disease-specific guideline from your MAC's LCD, with each element marked met, not met or not available.
5. 5.Comorbidities that contribute to the prognosis.
6. 6.Attending physician named by the patient, and whether they will certify.
7. 7.Certification status: oral date, written date, narrative present, signatures and benefit period dates checked before billing.

At election, the addendum listing conditions, items, services and drugs the hospice considers unrelated is now mandatory for every Medicare beneficiary; the FY 2027 hospice payment rates guide covers that change. The referral management guide explains staged intake, where eligibility evidence belongs in the gate before admission.

Recertification: Where Eligibility Is Lost

Eligibility is re-proved every period. Three rules matter most:

• Face-to-face encounter. For a patient anticipated to reach the third benefit period, a hospice physician or nurse practitioner must have a face-to-face encounter no more than 30 calendar days before the third-period recertification and every recertification after it. The narrative for those periods must explain why the encounter's findings support the prognosis. The manual says failing the encounter requirement means the patient ceases to be eligible.
• Telehealth limits. Under 418.22, encounters solely for recertification may use two-way audio-video through December 31, 2027. Since January 31, 2026, telehealth is not allowed if the patient is in an area under a hospice enrollment moratorium, the hospice is under enhanced oversight, or the practitioner is not enrolled in Medicare. From January 1, 2027, telehealth encounters must be reported on the claim.
• Stabilization. The LCD says a patient who improves enough that the prognosis is no longer 6 months or less should be considered for discharge, while a patient who stabilizes but has a reasonable expectation of continued decline remains eligible. Each recertification narrative should say which, with current numbers.

The update visits in the HOPE assessment guide produce symptom and function data every period; use them as decline evidence rather than collecting it twice.

Where Systems Help

Most eligibility denials trace back to evidence that existed somewhere but never reached the certification. Nuraflow is being designed so that intake and referral management prompts for missing information before admission, within its hospice workflows, where certification evidence stays with the episode it supports.

This article is general information, not clinical, legal or billing advice. Eligibility is a physician's clinical judgment; confirm documentation practices with your medical director, compliance officer and your MAC's current LCD.