Printable hospice eligibility criteria cards

What is in each PDF?

There are two PDFs with the same criteria, laid out for different uses. Both are in English and print on US letter paper.

Who are the cards for?

The cards are for clinicians and staff who spot decline and start the hospice conversation. Each group has its own guide.

• Physicians deciding whether to refer a patient, or certifying as the attending physician. See the physician guide.
• Hospital discharge planners and case managers. See the discharge planner guide.
• Skilled nursing facility staff, including nurses and social workers. See the skilled nursing guide.

How do I use the cards with the full eligibility pages?

Use a card to check the indicators quickly, then use the full page for the diagnosis to document the prognosis. The steps follow our hospice eligibility guidelines.

1. Step 1

   Start with the card for the diagnosis

   Note which indicators are met, which are not, and which could not be measured.

2. Step 2

   Check the general decline card

   Look at the last three to six months: function, activities of daily living, nutrition, infections, swallowing and use of acute care. Two or more serial scores or weights with dates show decline.

3. Step 3

   Open the full page for the diagnosis

   Each card prints a short link, such as betahospice.com/eligibility/dementia, to the full page. The full page has the indicator table, how to document each indicator, and its sources.

4. Step 4

   Use judgment and document it

   If the overall picture supports a prognosis of six months or less, say why in specific, measurable terms. A patient who does not meet the indicators may still be eligible. See what if the patient does not meet the guidelines?

5. Step 5

   Call or refer

   The referral card has our line, (877) 258-7129, answered by a hospice nurse at any hour, and our referral fax, (855) 563-3575. You can also refer a patient online.

How do I print the cards?

Print the cards PDF on letter paper at actual size, then cut once each way to get four cards from each page. Print the one-page sheet on letter paper.

Which LCD and contractor do the cards follow?

The cards condense LCD L33393, Hospice: Determining Terminal Status, the Medicare local coverage determination that Wellpoint Federal (formerly National Government Services) applies to California hospice claims as the Jurisdiction 6 Home Health and Hospice MAC. The billing and coding article is A52830 (LCD revision R4, effective April 1, 2026).

LCDs can be revised or retired, so verify the current text in the CMS Medicare Coverage Database before relying on any threshold. The LCD is guidance for clinicians and reviewers. The legal standard is 42 CFR 418.22: a physician certifies a life expectancy of six months or less if the illness runs its normal course. See the legal standard.

What if you are not sure a patient is eligible for hospice?

If you are not sure a patient is eligible for hospice, call Beta Hospice and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything. Have the card for the diagnosis in hand when you call. Prognosis is rarely clear cut.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.