CMS Model Examples of the Hospice Election Statement and Election Statement Addendum

The Centers for Medicare & Medicaid Services (CMS) has published model examples of the Hospice Election Statement and Election Statement Addendum in the download section of the Hospice spotlight web page. The model examples are not mandatory to use, as each hospice may design and print their own forms, but are suggested to ensure compliance of the information required on each form. 

The model example of the Hospice Election Statement includes all the required information outlined in section 20.2.1.1 of the Medicare Benefit Policy Manual Chapter 9 - Coverage of Hospice Services Under Hospital Insurance (PDF). Section 20.2.1.2 of Chapter 9 includes the addendum requirements, put in place for hospice elections beginning on or after October 1, 2020.

The CMS and HHH Medicare Administrative Contractors (MACs) highly recommend hospice agencies compare or model their forms to the examples CMS has provided. Non-compliant hospice election statements continue to be identified as a top denial reason by review contractors, including the MAC’s Targeted Probe and Educate process.