Hospice Election Statement Addendum: When “Unrelated” Care Must Be Explained

Hospice election statement addendum requirements make the hospice explain, in writing, which care it considers unrelated to a patient’s terminal illness and related conditions, and why it will not cover that care. For elections beginning on or after October 1, 2026, the hospice must give the patient or representative that explanation within the first five days of the election. A nurse sees the medication order. A biller sees who paid. The attachment puts the hospice’s explanation between them.

That makes it a useful document in hospice billing fraud involving costs pushed outside the benefit. The clinical reason for excluding a drug or service can be compared with the treatment plan and the claim that followed. The question is concrete: why did someone else pay for care the hospice was already being paid to provide?

When Do I Need a Hospice Election Statement Addendum?

For Medicare hospice elections beginning on or after October 1, 2026, every beneficiary or representative must receive a written addendum. The Centers for Medicare & Medicaid Services’ current hospice election rule makes provision automatic. The patient does not have to know enough to ask.

Earlier elections followed a request-driven rule, effective beginning October 1, 2020. A beneficiary, representative, non-hospice provider furnishing the excluded care, or Medicare contractor could request the explanation when the hospice had identified unrelated care. The election’s start date determines which delivery framework applies.

The election statement records the choice to receive hospice care and the patient’s understanding of the benefit. The addendum explains the hospice’s specific coverage decisions. The Notice of Election is another document: the hospice files it with its Medicare contractor.

What Must the Hospice Election Statement Addendum Explain?

The hospice election statement addendum lists the patient’s terminal illness and related conditions, identifies unrelated items, and gives a clinical rationale for excluding them. Its required title is Patient Notification of Hospice Non-Covered Items, Services, and Drugs. The hospice’s name, the patient’s name and medical record identifier connect the explanation to the person receiving care.

The agency’s March 2024 model shows the former request-based approach. Its August 2026 model reflects the mandatory approach.

The clinical explanation must say why the excluded care is unrelated and not needed for pain or symptom management, in language the patient can understand, with relevant clinical, policy or coverage guidelines. It must also say that the decision is made for each patient and that the patient should share it with other health care providers supplying unrelated care. It gives those providers the hospice’s clinical reasoning, rather than leaving them to guess what the hospice has agreed to cover.

The Centers for Medicare & Medicaid Services provides a model, but does not require a standardized form. In its final rule explaining the change, the agency also addresses the all-care-covered situation. The hospice still provides the attachment and records that determination in plain language. A document saying everything is covered gives an outside bill a clear point of comparison.

How the October 2026 Requirements Changed the Clock

The hospice election addendum October 2026 requirements move the initial delivery clock from a patient’s request to the election itself. Under the earlier rule, when a hospice beneficiary requested an addendum for excluded services, the request date mattered. Under the mandatory rule, staff can identify the initial deadline from the election’s effective date. Providing the attachment is a condition for Medicare payment.

A later change to the plan of care starts the update clock when it affects the attachment’s determinations. The hospice must give the written revision to the beneficiary or representative and update the copy filed with the election statement. An admission document can become an outdated explanation while care continues.

The model defines the date furnished as the date the beneficiary or representative receives the written attachment or update. The signature date is separate: signing acknowledges receipt, not agreement with the hospice’s reasoning.

For billing and compliance staff, the relevant sequence is the election, the written delivery, any change in the care plan, and the updated explanation. Those dates show which determination was in place when another provider supplied the care.

What Is Not Covered Under Hospice?

The hospice excludes care it determines is unrelated to the terminal illness and related conditions. The Centers for Medicare & Medicaid Services expects the hospice to provide virtually all care needed by the terminally ill patient and describes unrelated care as exceptional and unusual. The payment covers care needed to relieve and manage the terminal illness and related conditions, including medications and supplies for pain or symptom management.

This is where the attachment becomes more than admission paperwork. Medicare paid over $2.8 billion for non-hospice items and services under Parts A, B and D during hospice elections in fiscal 2024, according to CMS’s final rule. That was spending outside a benefit already designed to cover virtually all the patient’s care. The agency connected the increase to concerns about duplicate payment, care coordination and costs passed to beneficiaries.

The agency gave a pointed example: bronchodilators or oxygen treated as unrelated when a respiratory condition was the principal hospice diagnosis. It also questioned outside payment for wound care arising from the patient’s loss of mobility. The diagnosis, the symptom being treated and the reason given for excluding the treatment belong in the same conversation.

For hospice fraud involving cost shifting, the money can move without the patient’s need changing. Taxpayers pay the hospice, then Medicare receives another bill for care that should have been included. Patients can face bills for that care themselves. The attachment records the clinical explanation for drawing that boundary.

Hospice Medication Unrelated Determination Documentation: Who Pays for the Drug

Hospice medication unrelated determination documentation is the hospice’s written explanation of why the drug is outside its responsibility for this patient. The attachment, medication order, plan of care and pharmacy claim describe different parts of that decision. The formulary records which drugs the hospice ordinarily uses. The clinical explanation addresses why a particular patient’s drug is considered unrelated.

The agency says that drugs used to treat an illness may still offer symptom relief during hospice care. It also rejected the idea that a national list could resolve every relatedness decision. A drug’s role depends on the patient’s conditions and care needs. The attending physician, medical director and interdisciplinary group establish and review the care plan, as the Medicare hospice coverage manual explains.

A whistleblower’s complaint against MJHS Hospice and Palliative Care, a New York nonprofit hospice, alleged a medication practice that put this payment boundary into view. It described an off-formulary pain drug remaining in use while Medicare Part D picked up the charge:

The complaint also alleged that team meetings failed to review whether medications belonged under the hospice benefit or needed special authorization. It located those practices in nursing and assisted living facilities, where facility staff, outside prescribers and hospice nurses handled different parts of the medication process.

In Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities, its 2015 study of hospice payment incentives, the Office of Inspector General of the Department of Health and Human Services found that hospices typically provided fewer than five hours of visits per week while receiving about $1,100 a week for each beneficiary receiving routine home care in assisted living. The study analyzed hospice claims from 2007 through 2012. A daily payment puts the cost of covered care inside the hospice’s business. An outside medication claim can put an expense somewhere else.

For a healthcare insider, the useful comparison is between the reason recorded for the medication, the hospice’s explanation of noncoverage and the payer that received the bill. We work through that connection with you, including what the staff and managers knew about the payment decision.

What the Addendum Leaves in the Record

The original attachment and its updates preserve the hospice’s coverage decisions as the patient’s care changes. The filed copy is available to the patient or representative, outside providers and Medicare contractors.

A document recording that all care is related can be especially revealing beside an outside claim. So can a revised determination that follows a change in the plan of care. We compare the explanation in force at the time with the medication and service records, delivery dates and bills. That is how the attachment becomes useful evidence about a payment decision inside the business.

Hospice whistleblowers may see the medication decision, the billing instruction or the review that management ignored. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When the Explanation and the Bill Diverge

If you work in hospice nursing, pharmacy, billing or compliance and know why care was pushed outside the benefit, bring that payment decision to our whistleblower experts. We connect the clinical explanation, the claims and the decisions behind them to build your strongest hospice whistleblower case. We bring in hospice fraud whistleblower lawyers who understand medication coverage and Medicare billing, and stay beside you throughout the case.