Hospice Election Statement and Notice of Election Audits: Technical Denials You Can Avoid

Some of the most avoidable hospice denials have nothing to do with whether the patient was terminally ill. They come from technical requirements: an election statement missing a required element, an effective date earlier than the signature, a Notice of Election (NOE) filed late, or an attending physician change without a signed statement. Medical reviewers treat these requirements as conditions of payment, and a single missing item can lead to denial of an entire benefit period or many days of care.

The requirements are changing. CMS's FY 2027 hospice final rule requires hospices to provide the hospice election statement addendum to all Medicare beneficiaries who elect hospice on or after October 1, 2026, not only to those who request it. CMS announced it would exercise enforcement discretion from October 1 through December 31, 2026 while hospices adjust, but hospices should build compliant processes now.

This article explains the election statement requirements, the new addendum rules, NOE filing, late NOE consequences and exceptions, attending physician changes, common technical errors, and an audit checklist. It is educational and does not replace legal or professional advice.

The Election Statement

Who May Elect

Under 42 CFR 418.24(a), an eligible individual who elects hospice care must file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, a representative may file the statement.

Required Content

Under 42 CFR 418.24(b), the election statement must include:

• Identification of the hospice that will provide care and the attending physician, if any, along with the individual's or representative's acknowledgment that the attending physician was the individual's choice.

• The individual's or representative's acknowledgment that he or she understands the palliative rather than curative nature of hospice care as it relates to the terminal illness and related conditions.

• Acknowledgment that certain Medicare services are waived by the election. For elections on or after October 1, 2020, this includes information explaining that services unrelated to the terminal illness and related conditions are exceptional and unusual, and that the hospice should provide virtually all care needed.

• The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement.

• For elections on or after October 1, 2020, information about the individual's cost-sharing for hospice services.

• For elections on or after October 1, 2026, the election statement addendum described in the regulation.

• For elections on or after October 1, 2020, information about the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and contact information.

• The signature of the individual or representative.

CMS has published a model election statement that hospices may use as a guide.

Effective Date Rules

The effective date cannot be earlier than the date the statement is signed. A common error is an election statement dated after the first day of care, which leaves earlier days without a valid election. Another is a missing effective date.

Representatives

When a representative signs, the hospice should document why the individual could not sign and the representative's authority under state law. Reviewers may question signatures by people who are not legally authorized representatives.

The Election Statement Addendum

Background

Since October 1, 2020, hospices have been required to provide an addendum, upon request, listing conditions, items, services, and drugs the hospice has determined are unrelated to the terminal illness and related conditions and will not be covered by the hospice. CMS's FY 2027 final rule made the addendum mandatory for all Medicare beneficiaries electing hospice on or after October 1, 2026.

Required Content

Under 42 CFR 418.24(c), the addendum must be titled "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" and must include:

• The name of the hospice.

• The individual's name and hospice medical record identifier.

• Identification of the terminal illness and related conditions.

• A list of the individual's current diagnoses or 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 to be unrelated.

• A written clinical explanation, in language the individual or representative can understand, of why the identified conditions, items, services, and drugs are unrelated and not needed for pain and symptom management, with a general statement that relatedness decisions are made for each patient and that the individual should share this information with other providers.

• References to relevant clinical practice, policy, or coverage guidelines.

• Information on the purpose of the addendum and the right to immediate advocacy through the BFCC-QIO.

• Name and signature of the individual or representative and the date signed, with a statement that signing is only acknowledgment of receipt. If the individual or representative refuses to sign, the hospice must document the reason.

• Information that the addendum will be available to non-hospice providers and Medicare contractors on request.

• The date the hospice furnished the addendum.

Timeframes

Under 42 CFR 418.24(d):

• The hospice must provide the addendum in writing within the first five days of the effective date of the hospice election and file it with the election statement.

• If changes to the plan of care affect the relatedness determinations, the hospice must update the addendum within three days, provide it in writing, and update the copy in the file.

• If the individual dies, revokes, or is discharged before the addendum is furnished, delivery is not required, but the hospice must document the reason in the medical record.

• If the individual dies, revokes, or is discharged before signing, a signature is not required for payment, but the reason must be noted on the addendum.

Enforcement Discretion

CMS announced that from October 1 to December 31, 2026, while hospices are required to furnish the addendum to every electing beneficiary, it would exercise enforcement discretion. Hospices should still implement the requirement now and use this period to fix processes.

Why the Addendum Matters for Audits

CMS has emphasized concerns about Medicare spending outside the hospice benefit during a hospice election. The addendum documents the hospice's relatedness decisions. An addendum that is missing, late, generic, or inconsistent with the record may create both technical and coverage problems. Relatedness decisions must be clinically justified, and hospices should expect reviewers to compare the addendum with the plan of care and claims for unrelated services.

The Notice of Election

Filing Requirement

Under 42 CFR 418.24(e), the hospice must file the NOE with its Medicare contractor within five calendar days after the effective date of the election statement.

Consequences of Late Filing

If the NOE is not filed within the required timeframe, Medicare does not pay for hospice days from the effective date of election until the date the NOE is filed. These days are the hospice's liability and may not be billed to the beneficiary.

Exceptions

CMS may waive the late NOE consequence for exceptional circumstances, such as:

• Fires, floods, earthquakes, or similar unusual events that inflict extensive damage on the hospice's ability to operate.

• An event that produces a data filing problem due to a CMS or contractor systems issue beyond the hospice's control.

• A newly Medicare-certified hospice notified of certification after the effective date of certification, or awaiting its user ID from its contractor.

• Other situations CMS determines are beyond the hospice's control.

The hospice must fully document and furnish information about the circumstances to its MAC.

Practical Tips

• Count calendar days, not business days.

• Confirm that the NOE was accepted, not just submitted, and correct rejections immediately.

• Track NOE status daily.

• Make sure the effective date on the NOE matches the election statement.

Notice of Termination or Revocation

When a patient is discharged alive, revokes, or transfers, hospices must file the required notice with their MAC within the timeframe set in CMS's claims processing instructions. Late or missing notices can cause claim problems for the patient's other providers and for the hospice.

Changing the Attending Physician

Under 42 CFR 418.24(i), to change the designated attending physician, the individual or representative must file a signed statement with the hospice that:

• Identifies the new attending physician in enough detail to identify the physician clearly.

• Includes the date the change is to be effective and the date the statement is signed.

• Includes acknowledgment that the change was the individual's choice.

The effective date cannot be before the date the statement is signed. Hospices sometimes change attending physicians in their systems without a signed statement, which can create problems with claims and certifications.

Physician Enrollment

Physicians who certify hospice eligibility must meet Medicare enrollment requirements. CMS has required that physicians who certify hospice services be enrolled in Medicare or validly opted out. Hospices should verify the enrollment status of certifying physicians and attending physicians.

Writing Patient-Specific Relatedness Explanations

The addendum's written clinical explanation must be specific to the patient and understandable. Strong explanations:

• Name each condition the hospice considers unrelated and the items, services, or drugs involved.

• Explain in plain language why the condition does not contribute to the terminal prognosis and is not needed for pain and symptom management.

• Avoid generic statements copied for all patients.

• Reference relevant clinical guidelines where appropriate.

Example, for illustration only: "Your glaucoma eye drops are not related to your terminal diagnosis of metastatic lung cancer. Glaucoma does not affect your life expectancy and the drops are not needed to manage your symptoms from cancer. Medicare Part D or your other coverage may pay for these drops. Please share this information with your eye doctor and pharmacist."

Hospices should remember that CMS expects virtually all care to be related to the terminal illness and related conditions. Unrelated determinations should be exceptional and clinically justified.

Coordinating the Addendum With the Plan of Care

• Make relatedness decisions as part of the interdisciplinary group's initial assessment and plan of care.

• Document the clinical reasoning in the record, not only on the addendum.

• Update both the plan of care and the addendum when conditions change.

• Train pharmacy and clinical staff to review medications for relatedness consistently.

Explaining the Election to Patients and Families

Clear explanations reduce later disputes and complaints.

• Explain the palliative nature of hospice care in plain language.

• Explain which services the patient is waiving and what remains covered.

• Explain cost-sharing for drugs and respite care.

• Explain the right to revoke and to change hospices.

• Explain the BFCC-QIO's role and how to contact it.

• Document the conversation and the patient's or representative's questions.

Election Issues for Patients in Facilities

• Coordinate with nursing facility or assisted living staff on who will sign the election and when.

• Confirm representative authority before the representative signs.

• Make sure facility staff understand that the hospice is responsible for care related to the terminal illness.

• Provide copies of the addendum to the facility as appropriate.

Common Technical Errors

Election Statements

• Missing required elements, such as the attending physician acknowledgment, cost-sharing information, or BFCC-QIO information.

• Effective date earlier than the signature date.

• Missing effective date.

• Missing signature or date.

• Signed by someone without authority as a representative, or without documentation of why the individual could not sign.

• Outdated election statement forms that lack newer required content.

Addendum

• Not provided to all beneficiaries for elections on or after October 1, 2026.

• Provided late.

• Missing required content.

• Generic explanations not specific to the patient.

• Not updated when the plan of care changes.

• Missing signature or documentation of refusal.

NOE

• Filed after five calendar days.

• Rejected and not corrected promptly.

• Effective date mismatch with the election statement.

Attending Physician

• Changes without a signed statement.

• Effective date of change before the signature date.

Building a Compliant Admission Process

Before Admission

• Use current election statement and addendum templates that include all required elements.

• Train admission staff on each element and how to explain it.

• Verify the attending physician's identity and enrollment status.

• Confirm the representative's authority when applicable.

At Admission

• Review every element of the election statement before the patient or representative signs.

• Confirm the effective date is the same as or after the signature date.

• Provide the addendum, or schedule it within five days, with patient-specific relatedness determinations.

• Document education provided to the patient and family.

After Admission

• File the NOE promptly and confirm acceptance.

• Track the addendum due date and delivery.

• Update the addendum within three days when the plan of care changes affect relatedness determinations.

• Audit election packets for completeness.

Auditing Election and NOE Compliance

Step 1: Select a Sample

Choose recent admissions, including at least some elections on or after October 1, 2026.

Step 2: Review the Election Statement

Check every required element, the effective date, signatures, and representative documentation.

Step 3: Review the Addendum

Check delivery date, content, patient specificity, signature, and updates.

Step 4: Review NOE Timeliness

Compare the NOE filing and acceptance dates with the election effective date.

Step 5: Review Attending Physician Changes

Confirm signed statements for any changes.

Step 6: Quantify Impact

Calculate days affected by late NOEs or invalid elections.

Step 7: Correct and Educate

Update forms and processes, train staff, and evaluate overpayment obligations under 42 CFR 401.305 for claims paid without valid elections.

An Election Packet Audit Checklist

• Election statement identifies the hospice and attending physician, with acknowledgment of choice.

• Acknowledgment of palliative nature of care.

• Waiver and coverage information, including exceptional and unusual nature of unrelated services.

• Effective date present and not earlier than the signature date.

• Cost-sharing information.

• BFCC-QIO information.

• Signature and date of the individual or authorized representative.

• For elections on or after October 1, 2026, addendum provided within five days with all required content.

• Addendum updated within three days of relevant plan of care changes.

• NOE filed within five calendar days and accepted.

• Attending physician changes supported by signed statements.

A Hypothetical Example

A hospice audits 40 recent admissions and finds that six election statements used an older form without BFCC-QIO information, three had effective dates one day before the signature date, and four NOEs were filed on the sixth or seventh calendar day after the effective date. For elections after October 1, 2026, two addenda were provided on day seven.

The hospice replaces its forms, adds a hard stop in its EHR that prevents an effective date earlier than the signature date, sets daily NOE tracking with a same-day filing goal, and builds an addendum task due on day three to leave a margin before the five-day deadline. It calculates days affected by late NOEs, which were already unpaid, and evaluates whether any paid claims relied on invalid elections. A follow-up audit shows no errors in these areas.

Responding to Technical Denials

• Confirm the denial reason and the specific element at issue.

• Look for documentation that was available but not submitted.

• For late NOEs, consider whether an exceptional circumstance applies and whether it was documented and furnished to the MAC.

• Appeal when documentation supports compliance.

• Fix the process to prevent repeat errors.

Key Takeaways

• Use current election statement and addendum forms that include every required element.

• The election effective date can never be earlier than the signature date.

• The addendum is required for all elections on or after October 1, 2026, within five days.

• File the NOE within five calendar days and confirm acceptance.

• Document attending physician changes with signed statements.

• Audit election packets regularly to catch technical errors before reviewers do.

Frequently Asked Questions

When must the NOE be filed?

Within five calendar days after the effective date of the election.

What happens if the NOE is late?

Medicare does not pay for days from the effective date until the NOE is filed, and those days cannot be billed to the beneficiary, unless CMS grants an exception for exceptional circumstances.

Is the addendum now required for every patient?

Yes, for elections on or after October 1, 2026. CMS announced enforcement discretion through December 31, 2026.

When must the addendum be provided?

Within the first five days of the effective date of election, and updated within three days when relevant plan of care changes occur.

Can the election effective date be before the signature?

No. It may be the first day of hospice care or later, but no earlier than the date of the election statement.

Conclusion

Election statements, addenda, NOEs, and attending physician changes are technical requirements, but they are also conditions of payment. With the addendum now mandatory for elections on or after October 1, 2026, hospices should update forms, train admission staff, track deadlines, and audit election packets regularly. These steps can eliminate a category of denials that have nothing to do with patient care and everything to do with process.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps hospices avoid technical denials through election packet audits, form and template reviews, addendum process design, NOE tracking systems, and staff training. If you want to tighten your admission documentation, please get in touch with us. We will be happy to help you with this topic.

References

• Electronic Code of Federal Regulations. 42 CFR Part 418, Subpart B (including 418.24, Election of Hospice Care). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Federal Register. Medicare Program; FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements (August 3, 2026). https://www.federalregister.gov/documents/2026/08/03/2026-15686/medicare-program-fy-2027-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

• Centers for Medicare & Medicaid Services. Hospice News and Announcements (Initial Implementation of Mandatory Hospice Election Statement Addendum). https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/information-centers/hospices/news-announcements

• Centers for Medicare & Medicaid Services. Hospice Center. https://www.cms.gov/Center/Provider-Type/Hospice-Center

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c11.pdf

• U.S. Social Security Administration. Social Security Act, Section 1812(d), Hospice Care Election. https://www.ssa.gov/OP_Home/ssact/title18/1812.htm