When a patient elects to receive hospice care, Medicare requires that a doctor certify that the patient has a life expectancy of 6 months or less. However, some hospice patients live longer than the 6 month prognosis. This can happen for several reasons.
Why Do Some Hospice Patients Live Longer Than 6 Months?
There are a few key reasons why a hospice patient may live longer than the initial 6 month prognosis:
- The doctor’s prognosis was inaccurate – Predicting life expectancy is not an exact science. Doctors make the best clinical judgement they can, but there is always a degree of uncertainty.
- The patient responded better than expected to care – With the extra services and support provided by hospice, some patients gain strength and live longer than originally anticipated.
- The patient’s condition stabilized – For terminal illnesses like ALS, patients often steadily decline. But occasionally a patient’s condition levels off for a period of time.
- The initial prognosis was conservative – Some doctors give a cautious prognosis of 6 months or less, even if the patient may live longer. This ensures the patient qualifies for hospice care.
While unusual, it’s not uncommon for a small percentage of hospice patients to live for more than 6 months. Experts estimate 5-10% of hospice patients live longer than 6 months in the US.
Does Medicare Stop Covering Hospice Care After 6 Months?
Medicare continues to cover hospice care even if the patient lives longer than 6 months. Here are some key facts about ongoing hospice coverage under Medicare:
- After 6 months, Medicare requires the hospice provider to re-certify the terminal prognosis, but coverage continues.
- There is no limit on how long a Medicare beneficiary can receive hospice services.
- Hospice coverage will continue as long as a doctor re-certifies every 60-90 days that the patient has a life expectancy of 6 months or less.
- As long as doctors continue to re-certify terminal illness, Medicare hospice benefits can be renewed indefinitely.
So in short, Medicare does not cut off hospice services just because a patient lives longer than the initial 6 month prognosis. The key is that a doctor must continue to re-certify terminal illness for ongoing coverage.
Does the Hospice Provider Discharge Patients After 6 Months?
In most cases, hospice providers do not discharge patients just because they surpass the 6 month mark. The hospice will continue providing services as long as the following conditions are met:
- A doctor continues to certify that the patient is terminally ill with a prognosis of 6 months or less.
- The hospice interdisciplinary team determines that ongoing services are medically appropriate.
- The patient continues to meet other hospice eligibility requirements (e.g. the condition is still considered terminal).
However, in some rare cases, a hospice provider may determine discharge is appropriate if it seems the prognosis is inaccurate or services are no longer medically necessary. But typically care continues if the doctor re-certifies terminal illness.
Reasons a Hospice Might Discharge After 6 Months
Reasons a hospice provider may discharge a patient who lives longer than 6 months include:
- The condition seems to no longer be terminal or end-of-life.
- The plan of care no longer aligns with terminal condition.
- Health improves and life expectancy appears greater than 6 months.
- The terminal prognosis no longer seems accurate.
But again, in most cases care continues as long as the doctor re-certifies terminal illness and the hospice team determines services remain appropriate.
Does Hospice Stop Covering Certain Services After 6 Months?
The comprehensive hospice benefit does not change or become limited after a patient reaches 6 months. The same services stay covered, including:
- Nursing care
- Medical equipment
- Medications
- Therapies
- Home health aides
- Grief support
- Social work
- Spiritual care
- Volunteer services
As long as the doctor continues to re-certify terminal illness, Medicare covers the complete hospice benefit. No services are stopped or limited at 6 months.
Key Facts About Ongoing Hospice Coverage
- All core hospice services continue to be covered after 6 months.
- There are no service limits based on how long a patient is on hospice.
- The comprehensive hospice benefit continues as long as eligibility requirements are met.
- Ongoing services do not change even if the patient lives longer than expected.
Does the Level of Hospice Care Change After 6 Months?
The level of hospice care a patient receives is based entirely on their current condition, needs, and care plan. It does not change because a patient passes the 6 month mark. Some key points:
- Patients continue receiving the appropriate level of care based on health status.
- If condition declines, higher levels of care are provided, just as during the first 6 months.
- Levels of care are not downgraded or limited due to longevity.
- Care levels may fluctuate up or down based on changing needs.
So the duration of hospice care does not impact the level of services provided. Those are separate determinations based on real-time patient needs.
Hospice Care Levels
The four levels of hospice care are:
- Routine Home Care – Care provided at the patient’s home when symptoms are stable.
- Continuous Home Care – Increased care, often with a nurse on-site, during periods of crisis.
- Inpatient Respite Care – Short-term stay for the patient at an inpatient unit to give family respite.
- General Inpatient Care – Round-the-clock care during periods of uncontrolled symptoms.
The hospice team determines the appropriate level based on real-time patient/family needs.
Can a Hospice Patient Stop Services and Return Later?
Yes, a hospice patient can temporarily stop or “revoke” their hospice services, then return to hospice care later. Here is an overview of revoking hospice care:
- The patient (or family) must sign a form to revoke the hospice benefit.
- This ends the current hospice benefit period. Regular Medicare coverage resumes.
- There is no limit on how many times care can be revoked then resumed.
- To resume hospice care, the patient will need to be recertified by a doctor as terminally ill.
Revoking hospice care gives patients flexibility if they live longer than expected. They can take a break from services and return when end-of-life nears again. This revoke/resume process can happen multiple times.
Key Facts About Revoking Hospice Care
- Care can be revoked/stopped at any time by signing a form.
- Medicare coverage returns to regular Part A and Part B services.
- When ready to return, the patient must get a new terminal prognosis.
- There is no limit or maximum on how many times care can be revoked/resumed.
What if a Patient No Longer Qualifies for Hospice?
If a hospice patient’s condition improves such that they no longer have a terminal prognosis of 6 months or less, they would be discharged from hospice care. At this point, a few things happen:
- The patient returns to standard Medicare Part A and Part B coverage.
- Any related hospitalization costs are covered by Medicare Part A.
- Medicare Part B would resume covering doctor visits, test, therapies, etc.
- Prescription costs may rise without hospice covering medications.
So when a patient no longer meets the hospice eligibility criteria, they transition back to regular Medicare services. With improved health, the hope is they no longer need an end-of-life care program.
The Hospice Discharge Process
When discharging a patient who is no longer terminally ill, the hospice will:
- Notify the physician and document reasons for discharge.
- Coordinate transfer of care back to patient’s regular doctor.
- Provide a final summary of care notes and visit records.
- Forward medications and orders to the new attending physician.
- Provide any required durable medical equipment and supplies.
- Send written notice explaining the change in care.
This transition aims to ensure ongoing continuity of appropriate care tailored to the patient’s current health status.
Does the Hospice Benefit Have a Lifetime Maximum?
There is no lifetime maximum or cap on the total time a Medicare beneficiary can receive hospice care. As long as a doctor continues to certify terminal illness, hospice care can continue indefinitely. Key facts:
- There is no “lifetime limit” on days or visits covered by the hospice benefit.
- Patients can move on and off hospice care multiple times if needed.
- Total duration of hospice care across all benefit periods is unlimited.
- Ongoing care is based on eligibility, not prior duration of services.
So in summary, the length of time a patient receives hospice care does not impact their eligibility for ongoing services. There is no lifetime maximum under Medicare’s hospice benefit.
Average Length of Time on Hospice
While hospice care can continue indefinitely based on need, the average length of service is:
- Median hospice stay: 18 days
- Mean hospice stay: 71 days
- 10% of patients receive hospice care longer than 180 days
So while a small percentage of patients receive extended hospice care, the majority have service durations under 3 months total.
Conclusion
While Medicare requires a 6 month or less prognosis to initiate hospice care, services typically continue regardless of longevity. As long as a doctor re-certifies ongoing terminal illness, care continues at the same levels. There are also no lifetime limits or maximums under the hospice benefit. With proper eligibility, hospice services can be received indefinitely based on need. So longevity alone is not a reason for discharge or denial of ongoing services.