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Hospice Election Requirements

Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 9, §10, §20.2.1 and 40.1.3.1External PDF

To receive hospice services under the Medicare Hospice Benefit, the patient (or his/her authorized representative) must elect hospice care by signing an election statement. Each hospice designs and prints their own election statement.

The fiscal year 2021 Hospice Final Rule (CMS-1733-FExternal PDF) included new hospice election statement and addendum requirements effective for all hospice elections beginning on or after October 1, 2020.

As you develop your own hospice election statements and certifications of terminal illness, please review the revised:

  • Model Example of Hospice Election Statement – March 2024External PDF
    • Changed timeframe for addendum: “If I request this form within the first 5 days of the election start date, the hospice must furnish the written addendum within 5 days of the request date.”
    • Changed “BFCC-QIO Phone Number or Website”
    • Changed/simplified Signature area
  • Model Hospice Election Statement Addendum – March 2024External PDF
    • Updated “Purpose of Issuing this Notification”
    • Changed Signature area
      • Added/changed: "Note: The ‘date furnished’ is defined as when the beneficiary (or representative) receives an addendum within 3 or 5 days from their request and not the date of the signature."

The hospice's election statement must include the following:

  • Identification of the particular hospice that will provide care to the patient;
  • The patient's or representative's (as applicable) acknowledgment that the patient has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment;
  • The patient's or representative's acknowledgment that the patient understands that certain Medicare services are waived by the election;
  • The effective date of the election, which can be the first day of hospice care or a later date, but cannot be a retroactive date;
  • The patient's or representative's designated attending physician (if they have one). Include enough detail to clearly identify the attending physician. This may include, but is not limited to, the physician's full name, office address, or National Provider Identifier (NPI).
  • The patient's or representative's acknowledgement that the designated attending physician was their choice.
  • The signature of the patient or their representative.
  • Information about the holistic, comprehensive nature of the Medicare hospice benefit;
  • A statement that, although it would be rare, there could be some necessary items or services that will not be covered by the hospice because the hospice has determined that these items or services are to treat a condition that is unrelated to the terminal illness and related conditions.
  • The statement would also include information about possible beneficiary cost-sharing for hospice services.
  • Notification of the beneficiary's (or representative's) right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions and that expedited advocacy is available through the Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) review if the beneficiary (or representative) disagrees with the hospice's determination.

NOTE: If the patient/representative wants to change their designated attending physician, they must file a signed statement with the hospice. The statement must include the following information:

  • Identification of the new attending physician. Include enough detail to clearly identify the new attending physician. This may include, but is not limited to, the physician's full name, office address, or the NPI;
  • The date the change is effective;
  • An acknowledgement that the change in attending physician was their choice;
  • The patient's or representative's signature; and
  • The date the statement was signed.

A hospice election statement, or statement changing the designated attending physician, that is missing any of the bulleted items above, is considered incomplete, and may result in a claim denial.

Revised: 04.22.24

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