October 1, 2020 Hospice Changes: Hospices Must Provide Beneficiaries Addenda Outlining Conditions, Services, and Drugs Not Covered By Hospice

Footnotes for this article are available at the end of this page.

In an effort to increase coverage transparency, for hospice elections beginning on or after October 1, 2020, the beneficiary, beneficiary’s representative, non-hospice providers, or Medicare contractors may request a written addendum to the election statement which outlines which conditions, items, services, or drugs are unrelated to the patient’s terminal illness and related conditions.1  The signed addendum and any signed updates are a new Medicare condition for payment.  However, in issuing the rule, CMS clarified that this does not mean that the beneficiary needs to agree with the hospice’s determination.2

Content of the Addendum

The election statement addendum must be titled “Patient Notification of Hospice Non–Covered Items, Services, and Drugs” and must include the following, among other information:

  • A list of the beneficiary’s conditions present 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.
  • A written clinical explanation as to why the identified conditions, items, services, and drugs are considered unrelated to the beneficiary’s terminal illness and related conditions and not needed for pain or symptom management. This clinical explanation should 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 beneficiary and that the beneficiary 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.
  • Language that immediate advocacy is available through the Medicare Beneficiary and Family Centered Care–Quality Improvement Organization (BFCC–QIO) if the beneficiary disagrees with the hospice’s determination of non-coverage.3

The beneficiary or representative must sign the addendum as acknowledgment of receipt.  However, a signature does not necessarily indicate the beneficiary’s or representative’s agreement with the hospice’s determinations.  When issuing the final rule, CMS recognized that there may be rare instances in which the beneficiary or representative may refuse to sign the addendum but did not provide further guidance addressing such situations.4   The condition of payment is met if there is a signed addendum and any signed updates in the requesting beneficiary’s medical record with the hospice, but the addendum is not required to be submitted routinely with each hospice claim.5   Should a beneficiary or representative refuse to sign, we recommend the hospice document the date on which the addendum was provided and the reason for the refusal.

Timing

If the election statement addendum is requested at the time of initial hospice election, upon admission to hospice, the hospice must provide the addendum, in writing, to the individual within five days from the date of the election.  If this addendum is requested during the course of hospice care and after the hospice election date, the hospice must provide the addendum within seventy-two hours of the request.  If there are any changes to the addendum during the course of hospice care, the hospice must update the addendum and provide these updates, in writing, to the individual.7

Other Changes to the Election Statement:

 In addition, hospice providers must make the following updates to the Election Statement itself to include the following:

  • Notification of the beneficiary’s right to receive an election statement addendum, if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice;
  • Information on the BFCC–QIO, including the beneficiary’s right to immediate advocacy and the BFCC–QIO contact information;
  • Information indicating that services unrelated to the terminal illness and related conditions are exceptional and unusual and hospice should be providing virtually all care needed by the individual who has elected hospice; and
  • Information on individual cost-sharing for hospice services. 8

Note, while the addendum is only required to be furnished to beneficiaries, their representatives, non-hospice providers, or Medicare contractors who requested such information, the election statement modifications as outlined above apply to all hospice elections.

For more information, please contact H. Carol Saul and Charmaine A. Mech.

 

[1] 42 C.F.R. § 418.24.

[2] 85 F.R. 47087.

[3] 42 C.F.R. § 418.24(c).

[4] 85 F.R. 47087-47088.

[5] 85 F.R. 47087.

[6] 42 C.F.R. § 418.24(c).  If a beneficiary requests the addendum at the time of hospice election and dies within five days from the start of the hospice election and before the hospice can furnish the addendum, the hospice would not be required to furnish such addendum after the patient has died.  85 F.R. 47088.

[7] 42 C.F.R. § 418.24(c).

[8] 42 C.F.R. § 418.24(b).

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