Hospice Election Statement Addendum

20.2.1.2 Hospice Election Statement Addendum (Rev. 11056; Issued: 10-21-21; Effective: 10-01-21; Implementation: 12-22-21) For Hospice elections beginning on or after October 1, 2020, in the event that the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement. If the election statement addendum is requested within 5 days from the date of a hospice election, then the hospice would have 5 days from that request date to furnish the addendum. If the addendum is requested during the course of hospice care (that is, 5 days after the effective date of the hospice election), the hospice must provide this information, in writing, within 3 days of the request to the requesting individual (or representative), non-hospice provider, or Medicare contractor. 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). If the beneficiary dies, revokes, or is discharged within the required timeframe after requesting the addendum (i.e., within 5 days or 3 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. The “date furnished” must be within the required timeframe (that is, 3 or 5 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. If a beneficiary (or representative) refuses to sign a requested addendum, the hospice must document clearly on the addendum the reason the addendum is not signed. 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 would result in a claims denial. However, the Medicare Administrative Contractor 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). The election statement addendum must include the following: 1. The addendum must be titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” 2. Name of the hospice. 3. Individual's name and hospice medical record identifier. 4. Identification of the individual's terminal illness and related conditions. 5. 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. 6. A written clinical explanation, in language the individual (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 which they seek items, services, or drugs unrelated to their terminal illness and related conditions. 7. References to any relevant clinical practice, policy, or coverage guidelines 8. Information on the following: i. Purpose of Addendum. The purpose of the addendum is to notify the individual (or representative), in writing, of those conditions, items, services, and drugs the hospice will not be covering because the hospice has determined they are unrelated to the individual's terminal illness and related conditions. ii. Right to Immediate Advocacy. The addendum must include language that immediate advocacy is available through the Medicare Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) if the individual (or representative) disagrees with the hospice's determination. 9. Name and signature of the individual (or representative) and date signed, along with a statement that signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily the individual's (or representative's) agreement with the hospice'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. 10. The date the hospice furnished the addendum. The date furnished must be within the required timeframe (that is, 3 or 5 days of the beneficiary or representative request, depending on when such request was made). 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 5 days of the request. Therefore, the addendum would be required to be provided to Mr. Brown on or before December 8th. 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 5 days of the hospice election date), the hospice must provide this information, in writing, within 3 days of her request. Therefore, the addendum would be required to be provided to Mrs. Smith on or before December 7th. Example: Miss Jones requested the 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 5 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.