Choosing a hospice in Denver: what the Medicare data shows
Hospice eligibility comes down to one clinical judgment: a physician certifies that the patient has a life expectancy of six months or less if the illness runs its normal course. That is the whole legal standard. Everything else, the performance scales, the disease guidelines, the documentation, exists to support that judgment and to show a Medicare contractor how it was reached. Choosing which hospice to refer to is a separate question, and Medicare publishes data that answers it.
This page covers both. It is written for discharge planners, hospital case managers, SNF social workers, and physicians deciding where to send a referral, and for families weighing the same choice.
Optimal Hospice Care is a Medicare-certified hospice at 4380 S. Syracuse St., Suite 455, Denver, CO 80237. Our phone line is 303-488-9998. For an overview of our program and service area, see hospice care in Denver, CO.
How to qualify for hospice under the Medicare benefit
A patient qualifies for the Medicare hospice benefit when a physician certifies a terminal prognosis of six months or less if the illness follows its normal course. The patient also elects hospice, which means choosing comfort-focused care over curative treatment for the terminal condition.
For the first benefit period, two physicians must certify: the hospice medical director or hospice physician, and the patient's attending physician if the patient has one. Recertifications after that require only the hospice physician.
Benefit periods run in a fixed sequence. Two 90-day periods come first, followed by an unlimited number of 60-day periods. There is no cap on total time in hospice as long as the patient continues to meet the prognosis standard at each recertification.
Beginning with the third benefit period, and for every recertification after it, a hospice physician or hospice nurse practitioner must complete a face-to-face encounter with the patient. That encounter has to document clinical findings supporting a life expectancy of six months or less.
A prognosis is a clinical estimate, not a guarantee. Patients who stabilize on hospice and still show a reasonable expectation of continued decline remain eligible. Patients who improve substantially can be discharged and can elect the benefit again later.
Hospice eligibility criteria: what LCD L34538 actually requires
Colorado hospice claims are processed by CGS Administrators under Jurisdiction J-15. The governing local coverage determination is L34538, Hospice Determining Terminal Status, originally effective October 1, 2015, with a revision effective date of August 6, 2026. Verify the current text at the CMS Medicare Coverage Database before relying on any summary, including this one.
The LCD is structured in three parts, plus disease-specific guidelines.
Part I, decline in clinical status. Documented worsening across variables such as recurrent infections, progressive inanition, dysphagia, uncontrolled symptoms, and declining laboratory values. The LCD is explicit that no specific number of variables must be met. Findings listed earlier in the policy carry more predictive weight than those listed later.
Part II, non-disease specific baseline guidelines. Both of the following:
Karnofsky Performance Status or Palliative Performance Scale below 70 percent
Dependence on assistance with two or more activities of daily living, from feeding, ambulation, continence, transfer, bathing, and dressing
Two of the disease-specific guidelines, HIV disease and stroke and coma, set a lower qualifying KPS or PPS threshold.
Part III, comorbidities. Conditions that are not the primary hospice diagnosis but that should be weighed in the eligibility determination.
Disease-specific guidelines. The LCD retains sections for cancer diagnoses and for non-cancer diagnoses including ALS, dementia due to Alzheimer's disease and related disorders, heart disease, HIV disease, liver disease, pulmonary disease, renal disease, and stroke and coma. These are used in conjunction with the Part II baseline, not in place of it. This matters because the disease-specific criteria are still current policy, contrary to how they are sometimes described.
The criteria are guidelines, not a checklist
This is the single most misunderstood point in hospice referral, and it is worth quoting directly. The LCD states that some patients may not meet these guidelines yet still have a life expectancy of six months or less, and that coverage for those patients may be approved when documentation of clinical factors supporting a less than six-month prognosis, not included in the guidelines, is provided.
In practice: FAST stage 7a or beyond for Alzheimer's dementia, NYHA class IV with an ejection fraction of 20 percent or less for heart disease, and mMRC or GOLD staging with documented disabling dyspnea for pulmonary disease all function as strong clinical evidence. None of them is a required box to tick. A referral that does not hit a named threshold is still a referral worth making, provided the decline is documented.
If you are uncertain whether a patient qualifies, that uncertainty is itself a reason to call. Eligibility is determined by physician certification, not by a form. For families watching a decline and unsure of the timing, eight signs it may be time for hospice care is a plainer starting point.
What does hospice cover
Under the Medicare hospice benefit, coverage for the terminal illness and related conditions includes:
Nursing care and physician services
Medications for symptom control and pain relief related to the terminal condition
Medical equipment and supplies, including hospital beds, oxygen, and wound care supplies
Physical, occupational, and speech therapy where indicated for comfort and function
Medical social work
Chaplain and spiritual care
Hospice aide and homemaker services
Bereavement support for the family, continuing after the death
Short-term respite care and short-term inpatient care for symptom management
The benefit does not cover treatment intended to cure the terminal illness, and it does not cover room and board in a nursing facility or assisted living community. Care unrelated to the terminal condition continues to be billed to Medicare in the usual way.
The four levels of hospice care
Medicare defines four levels, and a patient can move between them as needs change.
Routine home care. The most common level. Scheduled visits from the care team wherever the patient lives.
Continuous home care. Predominantly nursing care provided in the home during a period of crisis, to manage acute symptoms.
General inpatient care. Short-term care in an inpatient setting for symptom management that cannot be handled at home.
Respite care. Short-term inpatient care to give family caregivers a break, up to five consecutive days at a time.
As a Medicare condition of participation, certified hospices maintain clinical on-call availability twenty-four hours a day, seven days a week. Our hospice levels of care and program overview explains how each level works in practice, and understanding the hospice care team describes who is involved at each one.
Does hospice come to your home
Yes. Hospice is a benefit defined by care, not by a building. Most hospice care is delivered wherever the patient already lives, whether that is a private residence, an assisted living community, a memory care setting, or a skilled nursing facility. The team travels to the patient.
Optimal Hospice Care serves Denver, Aurora, Centennial, Englewood, Greenwood Village, Cherry Hills Village, Glendale, Littleton, Lone Tree, Highlands Ranch, and Lakewood.
How to choose a hospice: reading the Medicare quality data
Every certified hospice publishes performance data on Medicare Care Compare. Most families and many referring clinicians never look, which is understandable, because the measures are not self-explanatory. Three of them carry real signal.
The Hospice Care Index
The Hospice Care Index is a claims-based composite. CMS evaluates ten separate indicators, including gaps in skilled nursing visits, early and late live discharges, burdensome transitions, skilled nursing minutes on weekends, and visits near death. A hospice earns one point per indicator it meets. Scores range from 0 to 10.
Optimal Hospice Care scores 10 out of 10. The national average is 8.8. The Colorado average is 9.5.
Because the index is built from claims rather than from a survey, it reflects the pattern of care actually delivered and billed, which is difficult to manage toward cosmetically.
Visits in the last days of life
This measure reports the percentage of patients who received a visit from a registered nurse or medical social worker on at least two of the final three days of life. It is the closest thing in the public data to a measure of whether a hospice is present when the family needs it most, and it is the measure with the widest spread between providers.
Optimal Hospice Care: 75.8 percent. National: 48.3 percent. Colorado: 62.3 percent.
For a discharge planner, this is the number worth checking on any hospice under consideration. Roughly half of hospices nationally do not reach the final three days at this rate.
Hospice comprehensive assessment at admission
This measure reports the percentage of patients who received all required elements of a comprehensive assessment at the start of care, covering pain, dyspnea, treatment preferences, and beliefs and values.
Optimal Hospice Care: 93.7 percent. National: 91.7 percent. Colorado: 91.4 percent.
The margin here is narrower than on the other two measures, which is expected. Comprehensive assessment is a floor that most hospices clear.
What to ask before you refer
What is the hospice's current Hospice Care Index score, and which indicators did it miss?
What percentage of its patients receive an RN or social worker visit in the last three days of life?
Is the agency Medicare-certified, and by what accrediting body is it surveyed?
Which levels of care does it actually provide, including continuous home care and general inpatient care?
How does it handle a patient who declines while in an assisted living or skilled nursing setting?
Ask any hospice for these figures directly. If a provider cannot produce them, that is information too.
The hospice referral process
A referral does not require a completed certification, a signed order set, or a determination that the patient definitely qualifies. It requires a phone call.
Call. A referral can come from a physician, a discharge planner, a case manager, a facility, a family member, or the patient. Reach Optimal Hospice Care at 303-488-9998.
Eligibility evaluation. A hospice clinician reviews the clinical picture against the LCD framework and coordinates with the attending physician.
Certification. The hospice physician and the attending physician certify the terminal prognosis for the first benefit period.
Election. The patient or an authorized representative signs the hospice election statement, choosing the benefit.
Admission and plan of care. The interdisciplinary team completes the comprehensive assessment and builds the plan of care with the patient and family.
Eligibility is determined by physician certification. Nothing on this page promises admission or coverage.
Frequently asked questions
Who qualifies for hospice care?
Any Medicare beneficiary whose physician certifies a prognosis of six months or less if the illness runs its normal course, and who elects comfort-focused care for that condition. There is no diagnosis requirement and no age requirement. The most common qualifying conditions include cancer, dementia, heart disease, pulmonary disease, stroke, renal disease, and liver disease. We cover these in more detail in our guide to hospice diagnoses.
How long can a person stay on hospice?
There is no time limit. The benefit runs in two 90-day periods followed by unlimited 60-day periods, with recertification at each one. Patients who live longer than six months remain eligible as long as the prognosis standard continues to be met.
Can a patient leave hospice and return later?
Yes. A patient can revoke the hospice election at any time and return to standard Medicare coverage, and can elect hospice again later if still eligible. A patient whose condition improves may also be discharged for extended prognosis and can re-elect if the condition declines again.
Does the patient give up their own doctor?
No. The patient may keep their attending physician, who works alongside the hospice team and participates in the initial certification.
What does hospice cost the family?
For patients with Medicare Part A, the hospice benefit covers care related to the terminal illness with no deductible. Medicare allows small copayments for outpatient drugs and respite care. Room and board in a facility is not covered by the hospice benefit. See accepted insurance for coverage outside of Medicare.
Talk to our team
Families: book your hospice eligibility call to talk through whether hospice fits your situation. Nothing is committed by asking. You can also reach Optimal Hospice Care directly at 303-488-9998.
Referral professionals: start a hospice referral with our team. The phone line is the direct referral path. Call 303-488-9998 to reach a hospice clinician who can evaluate eligibility with you, including for patients you are unsure about.
Optimal Hospice Care is Colorado-owned, established in 2004, Medicare and Medicaid certified, and ACHC accredited, serving the Denver metro from the Westgold Centre in the Denver Tech Center.
