CMS Pub. 100-02, ch. 9, § 20.2.1.1

An individual who meets the eligibility requirements of § 418.20 may file an election

statement with a particular hospice. If the individual is physically or mentally

incapacitated, his or her representative (as defined in § 418.3) may file the election

statement.

Each hospice designs and prints its election statement. The election statement must

include the following items of information:

1. Identification of the particular hospice that will provide care to the individual;

2. The individual’s or representative’s (as applicable) acknowledgment that the

individual has been given a full understanding of hospice care, particularly the

palliative rather than curative nature of treatment;

3. The individual’s acknowledgement that the individual has been provided

information on the hospice's coverage responsibility and that certain Medicare

services are waived by the election. For hospice elections beginning on or after

October 1, 2020, this would include providing the individual with information

indicating that services unrelated to the terminal illness and related conditions are

exceptional and unusual and the hospice should be providing virtually all care

needed by the individual who has elected hospice;

4. The effective date of the election, which may be the first day of hospice care or a

later date, but may be no earlier than the date of the election statement. An

individual may not designate an effective date that is retroactive;

5. The individual’s designated attending physician (if any). Information identifying

the attending physician recorded on the election statement should provide enough

detail so that it is clear which physician, Nurse Practitioner (NP), or Physician

Assistant (PA) was designated as the attending physician. This information

should include, but is not limited to, the attending physician’s full name, office

address, NPI number, or any other detailed information to clearly identify the

attending physician.

6. The individual’s acknowledgment that the designated attending physician was the

individual’s or representative’s choice.

7. For hospice elections beginning on or after October 1, 2020 the hospice must

provide:

• Information on individual cost-sharing for hospice services;

• Notification of the individual's (or representative's) right to receive an election

statement addendum if there are conditions, items, services, and drugs the

hospice has determined to be unrelated to the individual's terminal illness and

related conditions and would not be covered by the hospice;

• Information on the Beneficiary and Family Centered Care Quality

Improvement Organization (BFCC-QIO), including the right to immediate

advocacy and BFCC-QIO contact information.

8. The signature of the individual or representative.

An election to receive hospice care will be considered to continue through the initial

election period and through the subsequent election periods without a break in care as

long as the individual:

(1) Remains in the care of a hospice;

(2) Does not revoke the election; and

(3) Is not discharged from the hospice.

For Medicare payment purposes, an election for Medicare hospice care must be made on

or after the date that the hospice provider is Medicare-certified. As with any election, the

hospice must fulfill all other admission requirements, such as certification or

recertification, any required face-to-face encounters, or Conditions of Participation (CoP)

assessments. See also Pub. 100-04, Medicare Claims Processing Manual, chapter 11,

section 20.1.1.

An individual may change, once in each election period, the designation of the particular

hospice from which he or she elects to receive hospice care. The change of the

designated hospice is not considered a revocation of the election, but is a transfer. To

change the designation of hospice programs, the individual must file, with the hospice

from which he or she has received care and with the newly designated hospice, a signed

statement that includes the following information:

• the name of the hospice from which the individual has received care;

• the name of the hospice from which they plan to receive care; and

• the date the change is to be effective.

As described in Pub. 100-04, Medicare Claims Processing Manual, chapter 11, section

20.1.1, when a hospice patient transfers to a new hospice, the receiving hospice must file

a new Notice of Election; however, the benefit period dates are unaffected. The receiving

hospice must complete all assessments required by the hospice conditions of participation

as described in 42 CFR 418.54. Because the benefit period does not change in a transfer

situation, if the patient is in the third or later benefit period and transfers hospices, a face-to-face encounter is not required if the receiving hospice can verify that the originating

hospice had the encounter.

A change of ownership of a hospice is not considered a change in the patient’s

designation of a hospice and requires no action on the patient’s part.

Medicare beneficiaries enrolled in managed care plans may elect hospice benefits.

Federal regulations require that the Medicare contractor assigned the hospice specialty

workload maintain payment responsibility for hospice services and may pay for other

claims if that Medicare contractor is the geographically assigned Medicare contractor for

the managed care enrollees who elect hospice; for specifics, see regulations at 42 CFR

417, subpart P, 417.585, Special Rules: Hospice Care (b), and 42 CFR 417.531 Hospice

Care Services (b). Institutional claims for services not related to the terminal illness

would otherwise be the responsibility of another geographically assigned Medicare

contractor.

Managed care enrollees who have elected hospice may revoke hospice election at any

time, but claims will continue to be paid by fee-for-service Medicare contractors as if the

beneficiary were a fee-for-service beneficiary until the first day of the month following

the month in which hospice was revoked. As specified above, by regulation, the duration

of payment responsibility by fee-for-service Medicare contractors extends through the

remainder of the month in which hospice is revoked by hospice beneficiaries.

See Pub. 100-04, Medicare Claims Processing Manual, Chapter 2, “Admission and

Registration” and Chapter 11, “Processing Hospice Claims,” for requirements for hospice

reporting to the Medicare contractor.

20.2.1.2 Hospice Election Statement Addendum

(Rev. 11056; Issued: 10-21-21; Effective: 10-01-21; Implementation: 12-22-21)

For Hospice elections beginning on or after October 1, 2020, in the event that the hospice

determines there are conditions, items, services, or drugs that are unrelated to the

individual's terminal illness and related conditions, the individual (or representative),

non-hospice providers furnishing such items, services, or drugs, or Medicare contractors

may request a written list as an addendum to the election statement.

If the election statement addendum is requested within 5 days from the date of a hospice

election, then the hospice would have 5 days from that request date to furnish the

addendum. If the addendum is requested during the course of hospice care (that is, 5

days after the effective date of the hospice election), the hospice must provide this

information, in writing, within 3 days of the request to the requesting individual (or

representative), non-hospice provider, or Medicare contractor. If there are any changes to

the content on the addendum during the course of hospice care, the hospice must update

the addendum and provide these updates, in writing, to the individual (or representative).

If the beneficiary dies, revokes, or is discharged within the required timeframe after

requesting the addendum (i.e., within 5 days or 3 days of the request, depending on when

the request was made), and before the hospice has furnished the addendum, the

addendum would not be required to be furnished, and this condition for payment would

be considered satisfied. Likewise, if the beneficiary dies, revokes, or is discharged prior

to signing the addendum (furnished within the required timeframe), no signature is

required and this condition for payment would be considered satisfied.

The “date furnished” must be within the required timeframe (that is, 3 or 5 days of the

beneficiary or representative request, depending on when such request was made), rather

than the signature date. The hospice must include the “date furnished” on the addendum.

Only the beneficiary (or representative) is required to sign the addendum. The non-hospice provider is not required to sign the addendum, if they are the requesting entity. If

a beneficiary (or representative) refuses to sign a requested addendum, the hospice must

document clearly on the addendum the reason the addendum is not signed.

While the addendum is not submitted with hospice claims, it is a condition for payment if

the beneficiary (or representative) has requested it. This condition for payment is

satisfied when there is a beneficiary (or representative) request present, which is

documented by a valid signed addendum in the requesting beneficiary’s medical record

with the hospice. If the claim has been selected for medical review, and it is clear based

on received documentation that the beneficiary requested but did not receive the

addendum within the time period specified at 42 CFR 418.24(c), the failure to provide

such addendum would result in a claims denial. However, the Medicare Administrative

Contractor may request the addendum to accompany any additional documentation

request to mitigate such denial. A denial resulting from a violation of this specific

condition for payment would be limited to only the claim subject to review (that is, it

would not invalidate the entire hospice election).

The election statement addendum must include the following:

1. The addendum must be titled “Patient Notification of Hospice Non-Covered

Items, Services, and Drugs.”

2. Name of the hospice.

3. Individual's name and hospice medical record identifier.

4. Identification of the individual's terminal illness and related conditions.

5. A list of the individual's conditions present on hospice admission (or upon plan of

care update) and the associated items, services, and drugs not covered by the

hospice because they have been determined by the hospice to be unrelated to the

terminal illness and related conditions.

6. A written clinical explanation, in language the individual (or representative) can

understand, as to why the identified conditions, items, services, and drugs are

considered unrelated to the individual's terminal illness and related conditions and

not needed for pain or symptom management. This clinical explanation must be

accompanied by a general statement that the decision as to whether or not

conditions, items, services, and drugs are related is made for each patient and that

the individual should share this clinical explanation with other health care

providers from which they seek items, services, or drugs unrelated to their

terminal illness and related conditions.

7. References to any relevant clinical practice, policy, or coverage guidelines

8. Information on the following:

i. Purpose of Addendum. The purpose of the addendum is to notify the

individual (or representative), in writing, of those conditions, items,

services, and drugs the hospice will not be covering because the hospice

has determined they are unrelated to the individual's terminal illness and

related conditions.

ii. Right to Immediate Advocacy. The addendum must include language that

immediate advocacy is available through the Medicare Beneficiary and

Family Centered Care-Quality Improvement Organization (BFCC-QIO) if

the individual (or representative) disagrees with the hospice's

determination.

9. Name and signature of the individual (or representative) and date signed, along

with a statement that signing this addendum (or its updates) is only

acknowledgement of receipt of the addendum (or its updates) and not necessarily

the individual's (or representative's) agreement with the hospice's determinations.

If the individual (or representative) refuses to sign a requested addendum, the

hospice must document why (on the addendum itself) and it would become a part

of the medical record.

10. The date the hospice furnished the addendum. The date furnished must be within

the required timeframe (that is, 3 or 5 days of the beneficiary or representative

request, depending on when such request was made).

Example: Mr. Brown elects hospice on December 1st and requests the addendum on

December 3rd. The hospice must provide this information, in writing, to Mr. Brown

within 5 days of the request. Therefore, the addendum would be required to be provided

to Mr. Brown on or before December 8th.

Example: Mrs. Smith’s effective date of her hospice election was November 1st, but she

did not request the election statement addendum on that date. On December 4th, Mrs.

Smith requests the election statement addendum. Since Mrs. Smith requested the election

statement addendum during the course of hospice care (that is, after the first 5 days of the

hospice election date), the hospice must provide this information, in writing, within 3

days of her request. Therefore, the addendum would be required to be provided to Mrs.

Smith on or before December 7th.

Example: Miss Jones requested the election statement addendum on May 1st, the

effective date of her initial hospice election. Miss Jones died on May 3rd. Because Miss

Jones died within the first 5 days from the start of hospice care and before the hospice

was able to furnish the addendum, the addendum would not be required to be furnished

after Miss Jones has died, and this condition for payment would be considered met.