Hospice Recertification: How It Works

Recertification is the routine review where a hospice physician confirms a patient still has a terminal prognosis, allowing care to continue into the next benefit period. Under Medicare it happens on a fixed schedule: when the first 90-day period ends (the start of day 91), when the second 90-day period ends (day 181), and then before every 60-day period after that, with no limit on how many times. Only a physician (MD or DO) can sign it, and from the third period on a hospice physician or nurse practitioner must see the patient first. It's a normal part of long-term hospice care, and — contrary to a common fear — its purpose is to keep eligible patients enrolled, not to push them out.

The benefit-period schedule

The Medicare hospice benefit is structured as benefit periods: two initial 90-day periods, then an unlimited series of 60-day periods. At the beginning of each one, the hospice must recertify that the patient still has a prognosis of six months or less if the illness runs its normal course. A written certification is required for every period, even though the patient's original hospice election stays in effect the whole time. There is no maximum number of 60-day periods, so a patient who remains eligible can be recertified again and again. See what hospice benefit periods are for the full structure.

Certification vs. recertification (the "CTI")

The paperwork is called a certification of terminal illness, often shortened to "CTI" by hospice staff. The certification is the first one, signed when hospice begins; each one after that is a recertification. Both say the same thing — that the patient's life expectancy is six months or less if the illness runs its normal course — and both must be backed by clinical information filed in the patient's medical record.

Who certifies, and when

For the first benefit period, two physicians are involved: the hospice medical director (or physician designee, or the physician member of the hospice team) and the patient's attending physician, if they have one. For every period after that, the hospice physician's certification is sufficient. The certification is a written statement that the physician expects the illness to be terminal within six months on its normal course — it rests on clinical judgment supported by documentation of decline, not a single lab number.

Only a medical doctor or doctor of osteopathy can certify or recertify. A nurse practitioner or physician assistant can serve as a patient's attending clinician, but cannot sign the certification; in that case the hospice physician certifies.

Recertification deadlines

Medicare sets tight timing rules so the paperwork matches the period it covers:

• Earliest: a recertification can be completed no more than 15 calendar days before the next benefit period starts.
• Latest: if the written recertification isn't signed within 2 calendar days after the period begins, the physician must give an oral certification within those 2 days, which the hospice records in the chart.
• Before billing: the signed, dated written recertification must be on file before the hospice submits its claim to Medicare. A physician cannot sign it after the hospice has billed.
• Dates on the form: every certification and recertification must state the benefit-period dates it applies to.

These deadlines are the hospice's responsibility. Families don't file or sign anything for a routine recertification.

The face-to-face encounter

Starting with the third benefit period and before every period after that, Medicare requires a face-to-face encounter: a hospice physician or hospice nurse practitioner must see the patient no more than 30 calendar days before the new period begins, to gather the clinical findings used to decide continued eligibility. The clinician who made the visit signs an attestation with the visit date, and the certifying physician's narrative must explain why those findings support a prognosis of six months or less. This visit is the safeguard that keeps long-stay recertification grounded in the patient's actual condition. Read what a face-to-face encounter is for details on what happens during it.

Two details families often ask about:

• It can be by video, for now. Through December 31, 2027, a face-to-face encounter done only for recertification may be held by real-time two-way audio and video. Since January 31, 2026, video is not allowed if the patient lives in an area under a Medicare hospice enrollment moratorium, if the hospice is under enhanced Medicare oversight, or if the clinician is neither enrolled in nor formally opted out of Medicare.
• Switching hospices doesn't reset the clock. The requirement counts the patient's total stay across all hospices, and a transfer doesn't change the benefit period. If your loved one transfers in the third or a later period, the new hospice doesn't have to repeat the encounter when it can verify that the previous hospice already did it; every recertification after that still needs one.

Benefit period	Length	Who certifies	Face-to-face required?
1st	90 days	Hospice physician + attending physician (if any)	No
2nd	90 days	Hospice physician	No
3rd and beyond	60 days each (unlimited)	Hospice physician	Yes, within 30 days before each period

Recertification checklist: what a complete one includes

Under the federal hospice rule (42 CFR 418.22), a recertification is complete only when it has all of these. You don't need to check them yourself, but knowing them helps if a hospice ever tells you there's a paperwork problem:

• A statement that the patient's life expectancy is six months or less if the terminal illness runs its normal course.
• A brief narrative written by the physician about this patient's own clinical findings — no check boxes or standard wording used for every patient — placed right above the physician's signature, with a statement that the physician wrote it after reviewing the record or examining the patient.
• From the third period on, a narrative explanation of why the face-to-face findings support the prognosis, plus the visiting clinician's signed and dated attestation of the visit.
• Supporting clinical information filed in the medical record with the certification.
• The physician's signature and date, and the benefit-period dates it covers.

What the patient and family actually experience

For most families, recertification is nearly invisible — it's a clinical and paperwork process that happens around the visits you're already getting. Here's what it looks like from your side:

• No new test to pass. The physician reviews the documentation the team has been gathering all along; there's no special exam your loved one must endure.
• A face-to-face visit from period three on. A hospice physician or nurse practitioner sees the patient within the 30 days before the period starts. This often folds into the normal visit schedule.
• No bill to you. Recertification never generates a charge to the family, and there is no per-patient dollar limit on hospice care. (The Medicare "hospice cap" limits a hospice agency's total payments, not any one patient's care; see what the hospice cap is.)
• Care simply continues into the next period when the prognosis still holds, with no gap or re-enrollment paperwork for you.

What happens if a patient isn't recertified

If, at a recertification point, the physician can no longer certify a six-month prognosis — usually because the patient has stabilized or improved — the patient is discharged from hospice (a "live discharge") and care returns to standard Medicare. The hospice medical director must sign a written discharge order, and the patient loses the remaining days of that benefit period but owes nothing extra for the discharge.

You have a right to a fast appeal. The hospice should give you a Notice of Medicare Non-Coverage at least 2 days before hospice services end. To appeal, call the Medicare Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) listed on that notice no later than noon the day before the end date it shows.

This is not a punishment and it isn't final: there is no waiting period to come back. If the illness later progresses and a physician can certify the prognosis again, your loved one can re-elect hospice and start the next benefit period right away. A physician declining to recertify someone who has genuinely improved is the system working as intended, not a denial of needed care. See live discharge explained, can a doctor refuse to recertify hospice, and what if my loved one lives longer than six months.

What the physician actually documents

Recertification isn't a rubber stamp, but it also isn't a re-test the patient has to "pass." The hospice physician documents the clinical evidence of decline or continued terminal status — changes in weight, function, appetite, alertness, or symptom burden, along with relevant scores and findings. Region-specific guidance (sometimes called Local Coverage Determinations) offers region-variable reference points the hospice physician applies for various diseases, but these are clinical guides the physician weighs, not a single national checklist that automatically qualifies or disqualifies anyone. The judgment is holistic: does the overall picture still support a six-month-or-less prognosis if the illness runs its normal course? Families can help by keeping the team informed of any changes between visits, which makes the documentation more accurate and the recertification smoother.

Why long stays still get recertified

It surprises many families that someone can be on hospice for a year or more and keep being recertified. This is by design. Some terminal illnesses — advanced dementia, end-stage heart or lung disease, frailty — decline slowly and unpredictably. A patient can remain genuinely terminal while living longer than six months, because the six-month standard is a prognosis "if the illness runs its normal course," not a deadline. As long as the hospice physician can document continued decline or sustained terminal status at each benefit period — and the face-to-face encounter confirms it from the third period on — care continues. The unlimited 60-day periods exist precisely so that slow-declining patients are not cut off arbitrarily.

The misconception, corrected

Families often dread recertification, imagining it as a recurring threat to remove their loved one from hospice. In reality, recertification exists to confirm ongoing eligibility, not to ration care or to bill the family; when the prognosis still holds, the patient simply moves into the next benefit period. Medicare's own rules say a hospice may not discharge a patient because their care has become costly or inconvenient. And recertification never generates a charge to you.

Frequently asked questions

How often does recertification happen?

At the start of every benefit period after the first: on day 91 (the second 90-day period), on day 181 (the first 60-day period), and then every 60 days after that (days 241, 301 and so on) for as long as the patient stays on hospice and still qualifies. There is no limit on the number of 60-day periods.

When is the first recertification due?

At the start of the second 90-day period, on day 91 of hospice care. The physician may sign it up to 15 days before that date, and no later than 2 days after it begins (orally at first, if needed).

Who has to sign the initial certification?

The hospice medical director or a hospice physician, plus the patient's attending physician if they have one. Recertifications after that need only the hospice physician. Nurse practitioners and physician assistants cannot certify.

Does my loved one have to go somewhere for the face-to-face encounter?

No. A hospice physician or nurse practitioner comes to the patient, or — through December 31, 2027, with some exceptions — meets them by live video. It happens in the 30 days before the new period, and often within the normal visit schedule.

What if the face-to-face visit is missed?

Then the recertification is incomplete and Medicare won't pay for that period. Medicare expects the hospice to discharge the patient from the benefit but keep caring for them at the hospice's own expense until the visit happens, then re-admit them.

Can the doctor sign the recertification after Medicare is billed?

No. The written recertification must be on file before the hospice submits its claim. If it can't be written within 2 days of the period starting, an oral certification is recorded first.

Does switching hospices restart the benefit periods?

No. A transfer to another hospice does not change the benefit period, and the face-to-face rule counts the patient's total stay across all hospices.

Can recertification be denied just to save money?

Recertification turns on the physician's clinical judgment about prognosis, not on cost. Medicare does not allow a hospice to discharge a patient because care is costly or inconvenient, and there is no per-patient spending cap. You are never billed for recertification.

What if we disagree with a decision not to recertify?

Ask for the reason in writing, and use the Notice of Medicare Non-Coverage the hospice gives you to request a fast appeal from the BFCC-QIO by noon the day before services end. If the illness later worsens, your loved one can be re-evaluated and re-elect hospice with no waiting period.

Is there a limit to how many times you can be recertified?

No. The 60-day periods are unlimited. A patient who keeps meeting the terminal-prognosis standard can be recertified indefinitely.

Practical next steps

• Mark the schedule: note when each 90-day or 60-day period ends so the face-to-face visit (from period three on) isn't a surprise.
• Keep the team informed of changes in symptoms or function — this supports accurate certification.
• If you receive a Notice of Medicare Non-Coverage, read the end date and call the BFCC-QIO on it before noon the day before if you want a fast appeal.
• If recertification is declined, ask for the reason in writing and confirm your hand-off to regular Medicare.
• Remember re-enrollment is possible if your loved one later declines.
• Choosing or rechecking an agency? Compare hospices near you with CMS Care Compare quality measures.

Bottom line: recertification is the predictable, scheduled confirmation that hospice should continue. For eligible patients it's a formality that keeps care flowing — not a hurdle that ends it.