To receive hospice services under the Medicare benefit, a patient or his authorized representative must elect hospice care. 

If the patient or authorized representative elects to receive hospice care, the patient must file an election statement with a specific hospice agency. The election statement serves to indicate that the patient is choosing hospice care. 

The election statement and the election statement addendum are conditions for payment.

What is the structure of a hospice election form?

Every hospice agency can design and create their own hospice election statement form although Medicare has published a model form that can be used by hospice agencies Model Hospice Election Statement.  The election statement must include all of the following elements:

• Name of hospice agency that will be providing the services
• Acknowledge that nature of hospice services have been explained to the patient including, in particular, the palliative rather than curative nature of care
• Acknowledge patient understands that by electing hospice care, some Medicare services are waived 
• For hospice elections beginning on or after October 1, 2020, a statement that although it would be rare, there could be some necessary items, drugs, or services that may not be covered by hospice because these items are deemed to be unrelated to the terminal illness or related conditions
• The effective date of the election. This may be the first day of hospice care of a later day. But it cannot be a date that precedes the date that the election statement was signed by the patient or their authorized representative. 
• The individual who is serving as the patient’s attending physician, if any.
• Acknowledgement that the identified attending physician was the choice of the patient or authorized representative
• Signature of patient or authorized representative

There are some additional requirements for the election statements for elections beginning dated October 1, 2020 or later. These election statements must also include : 

• Information on patient cost sharing for hospice services
• Notification of the patient or authorized representative right to receive an addendum to the election statement. The addendum is only required to be furnished to beneficiaries, their authorized representatives, non-hospice providers, or Medicare contractors who request this information. This addendum includes a list and rationale for the items, drugs, or services that are not covered by hospice services because the hospice has deemed these to be unrelated to the terminal illness and related conditions. 
• Information on the Beneficiary and Family Centered Care Quality Improvement Organization (Beneficiary and Family Centered Care (BFCC) ), including that immediate advocacy is available through this organization if the patient disagrees with the hospice’s determination regarding non-covered services

Right to Request Patient Notification of Non-Covered Items, Services, And Drugs

At any time, a patient may request, in writing, the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. addendum to the election statement. 

The hospice agency must provide the notification within five days, if this request is made on the start of care date. 

If the request is made during the course of hospice care, the hospice agency must provide the requested notification within 72 hours.

If the patient (or authorized representative) requests the addendum at the start of care but dies with five days, the hospice is deemed to have met its requirement and is not required to provide the addendum.

When would a hospice update the addendum?

The addendum lists the patient’s diagnoses and conditions that are present upon hospice admission and the items, services, and drugs that are not covered by the hospice because they are deemed to be unrelated to the terminal illness and related conditions.

During the course of hospice care, the addendum may require update, for example, if the patient’s plan of care is updated.

Changes to the addendum will need to be signed by the patient or his authorized representative and stored in the patient’s medical record with the hospice agency. 

Where can you find more information on the election statement

• CMS hospice election requirements: Hospice Election Requirements
• Beneficiary and Family Centered Care (BFCC)-QIOs:  Beneficiary and Family Centered Care (BFCC)
• Sample CMS hospice election form: Model Hospice Election Statement