Hospice Election Statements: The Errors That Void a Benefit Period

Since October 1, 2026, every Medicare hospice election has required a signed election statement addendum alongside the election statement itself, under 42 CFR 418.24. CMS is exercising enforcement discretion on the addendum through December 31, 2026, so Medicare contractors will not deny a claim solely because the form is missing or incomplete during that window. The grace period ends. A hospice that gets the election statement or the addendum wrong now is building the file an auditor will use against the entire benefit period once it does.

Required Content of the Election Statement

42 CFR 418.24(b) lists eight required elements. The statement identifies the hospice and the attending physician, and the patient or representative must acknowledge that the physician was their own choice. It records the acknowledgment that hospice care is palliative rather than curative, discloses which Medicare services the election waives, and states the effective date, which cannot be earlier than the date the statement was signed. Since October 1, 2020, the statement has also disclosed individual cost-sharing and the right to advocacy through the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Because the hospice benefit remains carved out of Medicare Advantage, the same requirements apply regardless of which plan the patient is enrolled in. The signature itself, the final element, is where most findings turn up.

The Addendum, Mandatory for Every Election Since October 1, 2026

42 CFR 418.24(c) sets ten required contents for the addendum, titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs. It names the hospice, identifies the patient and the terminal illness and related conditions, and lists every condition present on admission the hospice has determined is unrelated, with the items, services, and drugs it will not cover. A written clinical explanation, in language the patient can understand, must accompany the list, the same discipline that defeats a medical necessity denial. The hospice furnishes the addendum within five days of the election's effective date and updates it within three days of any plan-of-care change affecting the determinations. CMS is granting hospices an enforcement discretion window through December 31, 2026, during which Medicare contractors will not deny a claim solely for a missing or incomplete addendum, while tracking compliance for the review ahead.

Signature, Date, and Filing Errors Auditors Flag

Hospices lose benefit periods on dates more often than on substance. The election's effective date cannot predate the date the statement was signed, and the hospice has only five calendar days from that effective date to file the Notice of Election (NOE) with its Medicare contractor. A late NOE carries a consequence beyond denial: 42 CFR 418.24(e)(1) turns every day between the effective date and the filing date into a provider liability the hospice may not bill to the patient. The addendum carries its own clock: five days to furnish it, three days to update it, and a signature and date once provided. A Recovery Audit Contractor (RAC) reviewing a hospice claim, or a Medicare Administrative Contractor during a Targeted Probe and Educate cycle, checks the election statement and addendum against the certification of terminal illness. An undated signature or a missing refusal note is as costly on review as a missing clinical explanation.

A hospice election statement missing the physician acknowledgment, or an addendum furnished a day past the five-day window, gives a reviewer grounds to question the entire election.

How a Defective Election Statement Reaches the Whole Benefit Period

To a Medicare auditor, an election statement with a missing or undated signature reads as a benefit period that was never validly elected, and every claim paid under it becomes an overpayment candidate. Once a contractor finds the defect in a sample of claims, extrapolation lets it apply that finding across the full lookback period, the methodology at the center of Medicare audit defense, turning a handful of flawed forms into a recoupment demand spanning every election the hospice processed the same way. The hospice's own paperwork becomes the government's evidence, which is why the forms deserve the same scrutiny as the clinical record behind them.

Why Early Legal Counsel Is Critical

It is critical that hospices promptly retain experienced healthcare defense counsel once a Medicare contractor requests election statements, addenda, or NOE filings for review. Early legal intervention can protect the hospice's rights, ensure the response accurately reflects what 42 CFR 418.24 actually requires, and preserve the defenses available before a sample finding becomes an extrapolated demand. Delaying legal representation after an audit request can significantly affect the outcome of the review.

How Health Law Alliance Can Help

Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience. If a Medicare contractor has requested election statements, addenda, or NOE filings for review, contact Health Law Alliance's hospice and home health audit defense attorneys for a free, confidential consultation.