Hospice Discharge

20.2.3 - Hospice Discharge (Rev: 13664; Issued: 03-05-26; Effective: 10-01-25; Implementation: 04-06-26) The hospice notifies the Medicare contractor of any discharge so that hospice services and billings are terminated as of that date. Upon discharge, the patient loses the remaining days in the benefit period. However, there is no increased cost to the beneficiary. General coverage under Medicare is reinstated at the time the patient revokes the benefit or is discharged. Once a hospice chooses to admit a Medicare beneficiary, it may not automatically or routinely discharge the beneficiary at its discretion, even if the care promises to be costly or inconvenient, or the State allows for discharge under State requirements. The election of the hospice benefit is the beneficiary’s choice rather than the hospice’s choice, and the hospice cannot revoke the beneficiary’s election. Neither should the hospice request or demand that the patient revoke his/her election. Discharge from a hospice can occur as a result of one of the following: • The beneficiary decides to revoke the hospice benefit; • The beneficiary transfers to another hospice; • The beneficiary dies; • The beneficiary moves out of the geographic area that the hospice defines in its policies as its service area. Some examples of moving out of the hospice’s service area include, but are not limited to, when a hospice patient moves to another part of the country or when a hospice patient leaves the area for a vacation. Another example would be when a hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which the hospice does not have a contract, and the hospice is unable to access the patient to provide hospice services. In this example, Medicare’s expectation is that the hospice provider would consider the amount of time the patient is in that facility and the effect on the plan of care before making a determination that discharging the patient from the hospice is appropriate; • The beneficiary’s condition improves, and he/she is no longer considered terminally ill. In this situation, the hospice will be unable to recertify the patient. The beneficiary can ask the Quality Improvement Organization (QIO) for an expedited review of the discharge (see Pub. 100-04, chapter 30, section 260 for more information); or • Discharge for cause: There may be extraordinary circumstances in which a hospice would be unable to continue to provide hospice care to a patient. These situations would include issues where patient safety or hospice staff safety is compromised. When a hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired, the hospice can consider discharge for cause. The hospice must do the following before it seeks to discharge a patient for cause: o Advise the patient that a discharge for cause is being considered; o Make a serious effort to resolve the problem(s) presented by the patient's behavior or situation; o Ascertain that the patient's proposed discharge is not due to the patient's use of necessary hospice services; and o Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the patient’s medical records. The hospice must notify the Medicare contractor and State Survey Agency of the circumstances surrounding the impending discharge. The hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult Protective Services) as appropriate. Discharge order: Prior to discharging a patient for any reason other than a patient revocation, transfer, or death, the hospice must obtain a written physician's discharge order from the hospice medical director. If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note. Effect of discharge: An individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice— • Is no longer covered under Medicare for hospice care; • Resumes Medicare coverage of the benefits waived; and • May at any time elect to receive hospice care if he or she is again eligible to receive the benefit. There is no waiting period for the hospice beneficiary to reelect the hospice benefit after discharge, and a subsequent election period can begin immediately after reelection if the individual continues to meet eligibility requirements. Discharge planning: The hospice must have in place a discharge planning process that takes into account the prospect that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill. The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill. Once a patient is no longer considered terminally ill with a life expectancy of 6 months or less if the disease runs its normal course, Medicare coverage and payment for hospice care should cease. Medicare does not expect that a discharge would be the result of a single moment that does not allow time for some post-discharge planning. Rather, it would be expected that the hospice’s interdisciplinary group is following the patient, and if there are indications of improvement in the individual’s condition such that hospice may soon no longer be appropriate, then planning should begin. If the patient seems to be stabilizing, and the disease progression has halted, then it could be the time to begin preparing the patient for alternative care. Discharge planning should be a process, and planning should begin before the date of discharge. In some cases, the hospice must provide Advanced Beneficiary Notification (ABN) or a Notice of Medicare Non-Coverage (NOMNC) to patients who are being discharged. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 30 “Financial Liability Protections”, Section 50.15.3.1, for information on these requirements.