Medicare Hospice Benefit Navigator & Recertification Engine

Clinical Scenarios 4 presets

Primary Diagnosis Model

Advanced Dementia / Alzheimer's (FAST 7A)

Statutory Trajectory Progress

Day 180 of 360

Current Statutory Period Live Discharge & Subsequent 60-day Re-admission

Interactive Day Scrubber (Days 1 to 360) Drag to navigate milestones

Period 1 (1–90d)
2 Physicians

Period 2 (91–180d)
1 Physician

Period 3 (181–240d)
F2F Encounter

Period 4+ (241d+)
Rolling 60d

Regulatory Compliance Status

Fully Compliant with CMS Hospice Benefit Regulations (42 CFR § 418.21 & § 418.22)

Physician Certification Rule

Initial 90-Day: Hospice MD + Attending Physician

Statutory Milestone: Day 180 Face-to-Face & Re-evaluation

At the conclusion of the second 90-day benefit period, the hospice medical director or hospice nurse practitioner must conduct a Face-to-Face (F2F) encounter prior to recertification for the 3rd benefit period (60-day). If disease has stabilized, live discharge is mandated under Medicare regulations.

Clinical Recertification Indicators PPS: 40%

Adjust patient indicators to simulate clinical eligibility assessments during statutory 60/90-day recertification checks.

Palliative Performance Scale (PPS)

Mobility, activity level, self-care ability

Functional Assessment Staging (FAST)

Alzheimer's/Dementia staging metric

Unintentional Weight Loss (>10% in 6 mo)

Nutritional decline and cachexia marker

Recurrent Aspiration / Severe Infections

Secondary complications in past 6 months

Clinical Prognosis Assessment: Patient meets CMS criteria for terminal prognosis certification (≤6 months if disease follows normal course).

Statutory Law vs Common Misconceptions

Misconception: "Hospice has a strict 6-month hard cap" +

42 CFR § 418.21

The Law: Medicare hospice benefits are structured as two initial 90-day periods followed by an unlimited number of 60-day periods. As long as a physician recertifies continued clinical decline/terminal prognosis, coverage continues indefinitely.

Misconception: "If a patient stabilizes, they are trapped" +

42 CFR § 418.26 & § 418.28

The Law: If a patient stabilizes or improves under palliative care, the hospice must discharge them ("live discharge"). The patient returns to standard Medicare Part A & B. If their condition declines later, they can immediately re-enroll without penalty.

Misconception: "Families cannot initiate contact without a doctor" +

CMS Hospice Guidelines

The Law: Anyone—the patient, family member, caregiver, or social worker—can contact a hospice agency directly for an informational consultation and clinical evaluation. The hospice will coordinate with the attending physician for formal certification.

Caregiver Actionable Protocol & Self-Referral Roadmap 4 of 4 steps verified

1. Direct Family Consultation & Self-Referral: You do not need to wait for a hesitant physician. Call any local Medicare-certified hospice agency directly for a 24-hour evaluation and comfort assessment.

2. Initial Two-Physician Certification (Days 1–90): Confirm that both the hospice medical director and the patient's attending physician sign the initial certification of terminal prognosis (≤6 months).

3. Face-to-Face Encounter Planning (Prior to Day 180+): Ensure the hospice schedules an in-person Face-to-Face encounter with a physician or hospice NP before the 3rd benefit period begins.

4. Understanding Revocation & Re-admission Rights: Patients or designated healthcare proxies retain the legal right to revoke the hospice benefit at any time for curative interventions, and can re-elect hospice whenever palliative goals resume.

Generated Clinical Care Trajectory & Recertification Report

Authoritative summary generated from current simulation parameters under 42 CFR § 418. Downloadable as a validated care trajectory record.