Hospice CoP Training - Spartan Coaching

What the Election Statement Is

The election statement is the beneficiary's (or representative's) formal filing of election of the hospice benefit with a particular hospice. If the individual is physically or mentally incapacitated, the representative as defined in 42 CFR 418.3 may file it.

The election statement is not a referral, not an intake form, and not a clinical assessment. It is a legal enrollment document with specific required elements — deficiencies in its content directly affect claim validity.

Required Election Statement Elements

The following elements are required under 42 CFR 418.24(b). Elections beginning on or after October 1, 2020 must also include the post-2020 elements.

Required Element	Details	Post-2020?
Hospice identification	Name of the specific hospice the beneficiary is electing	No — always required
Attending physician identification	Beneficiary's choice of attending physician (MD, DO, NP, or PA); acknowledgement it is the beneficiary's choice	No — always required
Palliative care acknowledgement	Acknowledgement of understanding that hospice care is palliative in nature	No — always required
Waiver of curative Medicare services	Acknowledgement of the waiver of certain Medicare-covered services related to the terminal illness	No — always required
Effective date	Date the election takes effect — may not be earlier than the date the statement is signed	No — always required
Beneficiary signature	Signature of the individual or authorized representative	No — always required
Cost-sharing information	Information on applicable cost-sharing under the hospice benefit	Yes — Oct 1, 2020+
BFCC-QIO immediate advocacy	Contact information and notice about immediate advocacy through the Beneficiary and Family Centered Care QIO	Yes — Oct 1, 2020+

Effective Date Rule — Critical

The effective date may be the same day as the signature date or a later date — it may never be earlier than the date the statement is signed. An election with a backdated effective date is noncompliant and creates a claim period that cannot be billed under that election.

Election Statement Addendum

For elections beginning on or after October 1, 2020, if the hospice determines there are conditions, items, services, or drugs unrelated to the terminal illness and related conditions, the beneficiary, representative, non-hospice providers, or Medicare contractors may request a written list as an addendum. 42 CFR 418.24(c)–(d)

Mandatory title: The addendum must be titled exactly “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.”

Required content: A patient-friendly clinical explanation of why each non-covered item is unrelated to the terminal illness and not needed for symptom management.

Required acknowledgement: The individual's (or representative's) name, signature, and date signed as acknowledgement of receipt, plus the date the hospice furnished the addendum.

When Request Is Made	Addendum Must Be Furnished Within
Within first 5 days of the hospice election date	5 calendar days of the request
After the first 5 days of the election date	3 calendar days of the request

CMS Policy Sources

CMS has manualized and clarified the addendum in MLN Matters change requests MM12015 and MM12491, and Transmittal 10437 to Pub. 100-02. Always verify addendum obligations against current manual guidance, not just the CFR alone.

Notice of Election (NOE) Filing

Separate from the beneficiary's election statement, the hospice must file the Notice of Election with its Medicare contractor (A/B MAC HHH). 42 CFR 418.24(e)

5-Calendar-Day Rule with Financial Consequences

The NOE must be filed within 5 calendar days after the effective date of the election statement. “Timely” means submitted to and accepted by the MAC within 5 days — submission alone is not sufficient if the NOE is rejected and must be resubmitted after day 5.

Late NOE = Provider liability: If the hospice does not file the NOE timely, Medicare will not cover or pay for hospice days from the effective date of election to the date of filing. These are provider-liable days. The hospice may not bill the beneficiary for these days.

Operational implication: Aim for same-day NOE submission where possible. Verify acceptance by the MAC — a rejected NOE that is resubmitted after day 5 creates provider-liable days for the gap period.

Exception process: If filing was late, exception categories and documentation requirements are specified in the Medicare Claims Processing Manual Pub. 100-04, Ch. 11 §20.1.1. Late NOE without documented exception = no recovery path.

Timeline	Action	Authority
Day 0 - election effective	Election statement signed; effective date established; prepare NOE	42 CFR 418.24(b)
Day 1-5 (aim: Day 0-1)	Submit NOE to MAC; confirm acceptance	42 CFR 418.24(e); Claims Manual Ch. 11 §20.1.1
Day 5+, if late	Document exception category; invoke exception workflow; report provider-liable days	Claims Manual Ch. 11 §20.1.1

What a Valid Referral Looks Like Under Medicare

Medicare does not create a single required referral form, nor does it require that a “referral” be written as a condition of coverage. Compliance focuses on what happens after election.

Operationally, a defensible internal definition of a valid referral is: a documented, time-stamped request containing enough information to (a) contact and locate the patient, (b) identify the likely terminal diagnosis and current condition, and (c) identify the attending physician and certifying physician pathway needed to complete admission within Medicare timelines.

Verbal referrals are acceptable as intake triggers — they do not substitute for required signed election documents or certification documentation. Acceptable referral sources include physicians, hospitals, SNFs, assisted living facilities, patients, and family members.

Key Regulatory Citations

Citation	Covers
42 CFR 418.24(b)	Required election statement content
42 CFR 418.24(c)–(d)	Election statement addendum — content, title, timeframes
42 CFR 418.24(e)	NOE filing requirement — 5-day window
MBPM Ch. 9 §20.2.1	Election statement requirements — operationalized
MBPM Ch. 9 §20.2.1.1	Effective date logic
Claims Manual Pub. 100-04, Ch. 11 §20.1.1	NOE timely filing, provider-liable days, exceptions
MLN MM12015	Election statement changes and addendum (effective Oct 1, 2020)
MLN MM12491	Addendum clarification and extension guidance

Knowledge Check

Election & Notice of Election

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