Election Statement and NOE Checklist

42 CFR 418.24 · Claims Manual Pub. 100-04, Ch. 11, §20.1.1 · MM12015 · MM12491

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Educational Use Only

Patient Name:

Date of Birth:

Medicare Beneficiary ID:

Election Effective Date:

Election Signature Date:

Benefit Period (1st / 2nd / etc):

5-Calendar-Day NOE Deadline

Election Effective Date (Day 0):

NOE Deadline (Day 5):

NOE Submitted:

MAC Acceptance Confirmed:

MAC acceptance - not just submission - must occur by Day 5. Late NOE = provider-liable days. Hospice cannot bill the beneficiary for late-NOE period. Pub. 100-04, Ch. 11 §20.1.1

Election Statement - Required Elements (42 CFR 418.24(b))

Identification of the hospice that will provide care418.24(b)(1)(i)

Patient's or representative's acknowledgment that the patient is terminally ill418.24(b)(1)(ii)

Acknowledgment that hospice care is palliative (not curative)Patient must affirmatively acknowledge this; do not rush past it 418.24(b)(1)(ii)

Identification of attending physician (if patient has designated one)Patient has the right to designate or change attending at any time 418.24(b)(1)(iii)

Acknowledgment of waiver of curative/duplicative services for the terminal conditionWaiver is for Medicare payment purposes; patient retains legal rights 418.24(b)(1)(iv)

Effective date of hospice electionMust not be earlier than the date the statement is signed 418.24(b)(1)(v)

Signature of patient or authorized representativeDocument capacity and representative authority if applicable 418.24(b)(2)

Date of signature418.24(b)(2)

Required Disclosures Added October 1, 2020 (42 CFR 418.24(b)(1))

These elements were added by the FY 2020 Hospice Final Rule. All election statements executed on or after October 1, 2020 must include them.

Contact information for the patient's BFCC-QIO (Beneficiary and Family Centered Care - Quality Improvement Organization)QIO information enables patients to raise concerns during the hospice election 418.24(b)(1)(vi)

Acknowledgment that the patient was informed about the hospice election addendum processPatient must be informed about the addendum option even if no non-covered items exist at time of election 418.24(b)(1)(vii)

Hospice's Medicare billing contact information418.24(b)(1)(viii)

Disclosure that Medicare pays the hospice a per diem rate that is all-inclusive for the terminal condition and related conditions418.24(b)(1)

Election Statement Addendum (42 CFR 418.24(c)-(d))

Determine whether any items, services, or drugs will not be covered by hospice because they are unrelated to the terminal condition (or hospice elects to exclude them)Document rationale for any excluded items clearly 418.24(c)

If exclusions exist: provide written addendum to patient within 72 hours of election (or by Day 1 of each benefit period)If patient requests addendum: must be provided within 72 hours 418.24(c)

Addendum content: list of excluded items, reason for exclusion, anticipated cost to patient, Medicare appeals information418.24(c)

Patient or representative signature obtained on addendumUnsigned addendum does not satisfy requirement 418.24(d)

Record Filing

Signed election statement filed in clinical record42 CFR 418.104(b)

NOE acceptance confirmation from MAC filed in record

Signed addendum filed (if applicable)42 CFR 418.24(d)

Copy of election statement provided to patient or representative

Sign-Off

Completed by:

Role:

Date:

Time NOE submitted:

Educational Use Only. Not legal advice. Verify against current primary sources and your organization's policies before use.