Hospice for Patients With Multiple Chronic Conditions

A person with several chronic conditions can qualify for hospice even when no single disease looks terminal on its own. Medicare's test is prognosis, not one particular diagnosis: a physician must certify a life expectancy of six months or less if the illness runs its normal course, and several conditions together can support that. The hospice must still name one condition, the one contributing most to the prognosis, as the principal (primary) diagnosis and list the others. A long problem list is not enough by itself; what counts is how severe the conditions are and whether the person is declining.

How hospice handles “more than one problem”

The federal Medicare agency (CMS) has written that “it is often not a single diagnosis that represents the terminal prognosis of the patient, but the combined effect of several conditions.” Federal rules require the hospice physician deciding on certification to consider the terminal condition, other health conditions (related or not), and current clinical information supporting all the diagnoses. For the first benefit period, the attending physician certifies too, if the person has one. Sorting the conditions matters for two reasons:

• It supports eligibility. CMS says a person may have conditions that individually would not make them terminally ill, but whose collective presence contributes to a terminal prognosis.
• It shapes coverage. Care for the terminal illness and related conditions flows through the hospice benefit; care for conditions truly unrelated to it continues through regular Medicare.

There is no family checklist that guarantees qualification. It rests on the doctor's prognosis judgment, and the right step is to request a hospice evaluation and ask whether there is any charge. For the basics, see who qualifies for hospice care.

Which conditions can count?

There is no national list. As one contractor's example, CGS's guideline (L34538) says that, even when they are not the primary hospice diagnosis, diseases such as these should be considered when their severity is likely to contribute to a life expectancy of six months or less: COPD, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, MS, Parkinson's), kidney failure, liver disease, cancer, AIDS and dementia. Wellpoint Federal's guideline (L33393) also names severe autoimmune disease, such as lupus or rheumatoid arthritis, that has stopped responding to treatment. Palmetto GBA's guideline for neurological conditions (L34547) asks whether the combined effects of the conditions are such that most people with those impairments would have a prognosis of six months or less. A condition counts because of how severe it is, not because it appears on a list.

What the physician looks for when no single disease meets its guideline

The general part of CGS's guideline lists signs of decline that is not reversible. They include:

• Recurrent or intractable infections, such as pneumonia or sepsis.
• Weight loss not due to a reversible cause such as depression or diuretics.
• Trouble swallowing with recurrent aspiration or shrinking food intake.
• Worsening symptoms, such as breathlessness or pain needing increasing doses of strong pain medicine.
• A Karnofsky or Palliative Performance Scale score that keeps falling after it is already under 70%.
• More ER visits, hospital stays or doctor visits related to the primary diagnosis.
• Needing help with more daily activities.
• Stage 3 or 4 pressure ulcers that progress despite good care.

No specific number of these has to be present, and other findings can count if they are documented. A low baseline alone (a score under 70% and needing help with two or more daily activities) does not qualify anyone. The details vary by region: CGS's general list gives no weight-loss figure, for example, while Wellpoint's general list says at least 10% of body weight in six months. Ask the hospice which contractor's guideline it works under.

How several conditions add up to a prognosis

It can be hard to understand how a person qualifies when no single illness looks “terminal enough” on its own. The key is that chronic conditions compound each other. Heart failure can damage the kidneys. Diabetes and high blood pressure are the most common causes of chronic kidney disease in adults. Weight loss and weakness leave little reserve to recover from a setback. CMS describes this as bodily systems being interdependent, and it expects the whole person to be assessed, not each disease scored separately.

A commenter gave CMS this example for its FY 2014 hospice rule: a man with dilated cardiomyopathy, an irregular heartbeat and pulmonary fibrosis, short of breath with activity but not at rest. His PPS had fallen to 50% in three months, he needed a walker and one person's help to walk less than 10 feet, he had lost 10% of his weight in six months, and he had been hospitalized twice in the past year for pneumonia and again last month for his heart rhythm. CMS's answer: any one of those conditions alone might not make him terminally ill, but their progression and collective presence contribute to a terminal prognosis. The certifying physician would choose the condition most contributory to the prognosis as the principal diagnosis and list the others, and that judgment must still be backed by clinical information.

Other combinations follow the same logic, for example:

• Advanced heart failure plus chronic kidney disease plus diabetes, with repeated hospitalizations for fluid overload and declining function between admissions.
• Several moderate conditions plus progressive weight loss, recurrent infections, falls and a shrinking ability to perform daily activities, the picture sometimes documented as debility or failure to thrive.

This is not unusual. When CMS looked at FY 2012 hospice patients whose claims listed only debility or adult failure to thrive, it found that over 50% had seven or more chronic conditions and 75% had four or more.

What care looks like

People juggling several illnesses can end up with a different specialist for each organ, conflicting advice, a long medication list, and repeated trips to clinics and emergency rooms. Hospice replaces that with one team and one written plan of care, prepared with the attending physician if there is one. The team (hospice physician, nurse, aide, social worker, chaplain or other counselor, and volunteers) provides:

• One coordinated plan for the terminal illness and related conditions. The hospice must also share information with any non-hospice providers treating unrelated conditions.
• Symptom relief across conditions, such as pain, breathlessness, swelling, nausea and fatigue.
• Medication review, keeping what supports comfort and simplifying what no longer helps; hospice doesn't automatically stop everything (how hospice handles your other medications).
• Equipment and supplies for the terminal and related conditions, plus those medications, covered by the Medicare hospice benefit (a copay of up to $5 per outpatient prescription may apply). See what the Medicare hospice benefit covers.
• A nurse and doctor on call 24 hours a day, 7 days a week, so there is someone to call before a problem becomes a crisis. Call the hospice before going to the ER or calling an ambulance, because Medicare may not pay for related care the team did not arrange (the ER and hospital on hospice).

Related vs. unrelated: who pays for what?

Expect nearly everything to go through hospice. Federal rules require hospices to tell patients that services unrelated to the terminal illness and related conditions are “exceptional and unusual” and that the hospice “should be providing virtually all care needed.” CMS has said that unless there is clear evidence a condition is unrelated to the terminal prognosis, all services will be considered related, and it has rejected the argument that long-standing, stable or well-controlled conditions are automatically unrelated. A long-standing condition such as diabetes is not automatically outside hospice. Occasionally something is genuinely separate, such as treatment for an injury that has nothing to do with the illness, and that care continues under regular Medicare.

The decision is made for each patient, and the hospice makes it. For anyone electing hospice on or after October 1, 2026, the hospice must give you a written addendum, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs,” within the first 5 days. It lists what the hospice considers unrelated and explains why in language you can understand, and the hospice must update it within 3 days if a change in the plan of care affects it. Signing only acknowledges that you received it, not that you agree. If you disagree, the addendum must tell you about immediate advocacy through Medicare's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

Situation	Typically covered by hospice?	Who pays otherwise
Medications for the terminal diagnosis and related conditions	Yes (copay up to $5 per outpatient prescription)	N/A
Symptom relief across the linked conditions	Yes	N/A
Equipment for the terminal and related conditions	Yes	N/A
Treatment for a clearly unrelated new problem	No	Original Medicare, with its usual deductible and coinsurance, or your Medicare Advantage plan if you stay in one
A drug unrelated to the terminal illness and related conditions	No	Your Medicare drug plan (Part D) may cover it, and a copay may apply
Room and board in a nursing home or assisted living	No, except a short inpatient or respite stay the hospice arranges	Usually the patient; for those who qualify, Medicaid may pay in a nursing home (room and board: who pays)

If you're ever unsure who pays for a given treatment, ask the hospice team to state plainly whether they consider it related to the terminal diagnosis.

The misconception, corrected

The most damaging myth is that “you can't get hospice unless one disease is clearly terminal.” CMS says eligibility is based on the prognosis of the individual, “not only a single diagnosis or multiple diagnoses.” That also means the reverse mistake is wrong: having many diagnoses does not qualify anyone by itself. A second myth is that hospice will “cut off” all the medicines for the other conditions. It won't: the team reviews each drug with the patient and family, and medicines that still help can continue.

Frequently asked questions

How does the hospice pick the “primary” diagnosis if everything is serious?

The certifying physician chooses the condition most contributory to the terminal prognosis, using the comprehensive assessment, other clinical information and clinical judgment. The other diagnoses go on the claim too. The label is for documentation and billing; the plan of care covers the terminal illness and all related conditions.

Can the primary diagnosis change later?

Yes. CMS says a new certification is not required simply because the principal diagnosis changes, and benefit periods and election status do not change because of it.

Will my parent lose their diabetes or heart medicines?

Not as a rule. The National Institute on Aging gives the example of a person with high blood pressure who still gets medicine for it on hospice. The team reviews each drug and may recommend stopping one that adds burden without comfort benefit, and your parent keeps the right to refuse treatment. If the hospice will not cover a drug, it must tell you why and whether you would have to pay.

Can they keep seeing their cardiologist or kidney doctor?

Partly. The person names one attending physician, who can be a specialist. Other care for the terminal illness and related conditions has to be given or arranged by the hospice team, so check first or Medicare may not pay. Specialists treating a truly unrelated condition can continue under regular coverage. See can you keep your own doctor.

What happens if a brand-new, unrelated illness comes up?

Care for a clearly unrelated problem continues under Original Medicare, or your Medicare Advantage plan if you stay in one, with the usual cost-sharing. Call the hospice first so it can say whether it considers the problem related; if the plan of care changes, it must update the addendum within 3 days.

Can someone on dialysis get hospice for a different illness?

Yes. Medicare's policy is that if the terminal condition is not related to kidney failure, the patient may receive covered services under both the ESRD benefit and the hospice benefit. See hospice on dialysis or with ESRD.

Does having many conditions make recertification harder?

The test is the same either way. At each benefit period a hospice physician must again certify a prognosis of six months or less and explain why in a brief narrative, and from the third period on, a hospice physician or nurse practitioner must see the patient face to face within 30 days beforehand. CGS's guideline says long stays or apparent stability can still be eligible, but the record has to justify the prognosis. Many conditions do not make that automatic. See how hospice recertification works.

Is “debility” or “failure to thrive” enough by itself?

Not as the main diagnosis. Since October 1, 2014, Medicare has returned hospice claims that list either one as the principal diagnosis; both can still be listed as additional diagnoses, and the weight loss and decline behind them still count as evidence. See whether failure to thrive or debility qualifies.

Practical next steps

• Bring a full problem list and medication list to the doctor and ask whether the combined picture supports a hospice referral.
• Bring a record of the decline: weights, infections, ER visits and hospital stays, and which daily activities now need help.
• Ask which condition would be the primary terminal diagnosis and which are considered related.
• Read the addendum to see what stays on regular Medicare, and ask about anything you do not understand.
• Compare local agencies and their family-survey scores when you compare hospices near you.