Hospice Documentation

Implementation of the Election Statement Addendum

Hospice Election Statement Addendum

Hospice care is a benefit under the hospital insurance program. To be eligible to elect hospice care under Medicare, the beneficiary must be entitled to Part A of Medicare and be certified as being terminally ill.

The beneficiary must also elect the hospice benefit by signing the hospice election statement provided by the hospice agency. The fiscal year 2021 Hospice Final Rule (42 CFR 418.24[b]) finalized modifications to the election statement adding new requirements that include the hospice election statement addendum.

For hospice elections beginning on or after 10/1/2020, if the hospice agency determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the beneficiary (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the Hospice Election Statement.

The goal of the addendum is to increase coverage transparency to allow beneficiaries the opportunity to make fully informed decisions as they approach the end of life. Additionally, it should promote a vehicle for discussion between the hospice agency and the beneficiary and ensure that this information is provided to the requesting beneficiary (or representative) in a timely fashion.

The Hospice Election Statement Addendum must include the following:

  • The addendum must be titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”;
  • The name of the hospice agency;
  • The beneficiary’s name and hospice agency medical record identifier;
  • Identification of the beneficiary’s terminal illness and related conditions;
  • 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;
  • A written clinical explanation, in language the beneficiary (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 whom they seek items, services, or drugs unrelated to their terminal illness and related conditions;
  • References to any relevant clinical practice, policy, or coverage guidelines;
  • Information on the following:
    • Purpose of Addendum. The purpose of the addendum is to notify the beneficiary (or representative), in writing, of those conditions, items, services, and drugs the hospice agency will not be covering because the agency has determined they are unrelated to the individual's terminal illness and related conditions.
    • Right to Immediate Advocacy. The addendum must include language that immediate advocacy is available through the Medicare BFCC-QIO if the beneficiary (or representative) disagrees with the hospice's determination.
  • The name and signature of the beneficiary (or representative) and date signed, along with a statement that signing the addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily the beneficiary’s (or representative's) agreement with the hospice agency’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;
  • The date the hospice furnished the addendum. The date furnished must be within the required timeframe (that is, three or five days of the beneficiary or representative request, depending on when such request was made).

Hospice agencies can design the format of the addendum to best meet their needs as long as the content requirements are met. CMS provided model examples on the Hospice Center webpage to assist hospices in understanding the requirements but hospices do not have to use these specific examples: Model Example of “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”.

Timeframe for Furnishing the Hospice Election Statement Addendum

The addendum is only given to the Medicare beneficiary (or their representative) when they request the information. While hospice agencies can choose to provide the addendum to every electing beneficiary, CMS is not requiring that it is mandatory, unless the beneficiary (or representative) requests the addendum.

The effective date of the hospice election is the first day of hospice care. The effective date is considered “Day 0”.

If a beneficiary requests the addendum within the first five days of the effective date of the election, the hospice has five days from the request date to furnish the addendum.

  • 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 five days of the request. Therefore, the addendum would be required to be provided to Mr. Brown on or before December 8th

If a beneficiary requests the addendum after the first five days of an election, the hospice has three days from the date of the beneficiary request to furnish the addendum.

  • 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 five days of the hospice election date), the hospice must provide this information, in writing, within three days of her request. Therefore, the addendum would be required to be provided to Mrs. Smith on or before December 7th.

If the beneficiary dies, revokes, or is discharged within the required timeframe after requesting the addendum (i.e., within five days or three 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.

  • Example: : Miss Jones requested the Hospice 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 five 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.

The “date furnished” must be within the required timeframe (that is, three or five 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.

Note: 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).

Condition for Payment

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 should result in a claims denial.

The MAC 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).

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Reviewed 8/2/2024