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Title 42 Chapter IV Part 418 Subpart B

§ 418.20—Eligibility requirements.

In order to be eligible to elect hospice care under Medicare, an individual must be:

  • (a) Entitled to Part A of Medicare; and

  • (b) Certified as being terminally ill in accordance with § 418.22.

§ 418.21—Duration of hospice care coverage - Election periods.

  • (a) Subject to the conditions set forth in this part, an individual may elect to receive hospice care during one or more of the following election periods:

    • (1) An initial 90-day period;

    • (2) A subsequent 90-day period; or

    • (3) An unlimited number of subsequent 60-day periods.

  • (b) The periods of care are available in the order listed and may be elected separately at different times.

[55 FR 50834, Dec. 11, 1990, as amended at 57 FR 36017, Aug. 12, 1992; 70 FR 70546, Nov. 22, 2005]

§ 418.22—Certification of terminal illness.

  • (a) Timing of certification

    • (1) General rule. The hospice must obtain written certification of terminal illness for each of the periods listed in § 418.21, even if a single election continues in effect for an unlimited number of periods, as provided in § 418.24(c).

    • (2) Basic requirement. Except as provided in paragraph (a)(3) of this section, the hospice must obtain the written certification before it submits a claim for payment.

    • (3) Exceptions.

      • (i) If the hospice cannot obtain the written certification within 2 calendar days, after a period begins, it must obtain an oral certification within 2 calendar days and the written certification before it submits a claim for payment.

      • (ii) Certifications may be completed no more than 15 calendar days prior to the effective date of election.

      • (iii) Recertifications may be completed no more than 15 calendar days prior to the start of the subsequent benefit period.

    • (4) Face-to-face encounter. As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.

  • (b) Content of certification. Certification will be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness. The certification must conform to the following requirements:

    • (1) The certification must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.

    • (2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information ...

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