Required Elements of a Hospice Election Statement: What Providers Must Include

When a patient chooses hospice care under Medicare, they must sign an election statement to formally begin receiving services. This document serves as a critical legal and clinical record that outlines the patient’s decision to transition from curative care to palliative care focused on comfort and quality of life.

While CMS (Centers for Medicare & Medicaid Services) does not require a specific template or format for the election statement, it does mandate that certain key elements must be included. Each hospice is responsible for designing its own statement—but compliance with the required content is essential to avoid survey deficiencies or billing issues.

Below is a breakdown of the required elements that every hospice election statement must contain.

1. Name of the Hospice Provider

The statement must clearly identify the name of the hospice agency that will provide care to the beneficiary. This affirms the provider’s role and responsibility for managing and coordinating the patient’s end-of-life care.

2. Explanation of Palliative, Not Curative, Treatment

The election statement must explain that hospice care is focused on palliative treatment, not curative therapies. This includes symptom management, pain relief, and psychosocial support rather than medical interventions aimed at curing the terminal illness.

This distinction is vital in helping patients and families understand the nature of hospice services and make informed decisions.

3. Waiver of Certain Medicare Services

By signing the election statement, the individual acknowledges that they are waiving the right to Medicare coverage for treatments intended to cure the terminal illness.

Beginning October 1, 2020, the statement must also include language that informs the patient:

• That receiving care for conditions unrelated to the terminal illness is exceptional and rare

• That the hospice will be responsible for managing virtually all care related to the terminal illness and associated conditions

This ensures clarity about the scope of care and what services are and are not covered under the Medicare hospice benefit.

4. Effective Date of the Election

The election statement must include the effective date, which is the date hospice care will officially begin. This is especially important for care coordination, billing, and compliance.

5. Designation of Attending Physician

If the patient chooses to keep their own physician involved in their care, the statement must name the attending physician, if any, and their role in the care plan.

6. Acknowledgment of Attending Physician Choice

The patient (or their legal representative) must acknowledge in writing that the attending physician was chosen freely by the individual. This protects the patient's autonomy in selecting their preferred healthcare provider.

7. Cost-Sharing and Addendum Rights (Effective October 1, 2020)

Per recent CMS updates, the election statement must now also include:

• An overview of the individual’s cost-sharing responsibilities (such as co-payments for certain drugs or inpatient respite care)

• The individual’s right to request an addendum explaining non-covered services (e.g., items or care the hospice determines to be unrelated to the terminal illness)

• Information about the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including:

  • The patient’s right to immediate advocacy

  • How to contact the BFCC-QIO for questions, complaints, or concerns about coverage

8. Signature of the Individual or Authorized Representative

Finally, the election statement must be signed and dated by the individual or their legally authorized representative (e.g., health care proxy, power of attorney). This formalizes the election and confirms that the information was reviewed and understood.

Summary: What Hospices Must Remember

While CMS gives flexibility in how the election statement is formatted, every hospice must include all required elements to remain in compliance. Failure to do so could result in:

• Payment delays or denials

• Survey citations or deficiencies

• Misunderstandings between the hospice and the patient or family

Hospices should regularly review and update their election forms to reflect the most current CMS requirements.

How SummitRidge Can Help

At SummitRidge, we assist hospice agencies in developing and reviewing their core documentation—including compliant, customized hospice election statements. Whether you're launching a new agency or auditing your existing processes, we ensure your documents meet CMS standards and are survey-ready.

Contact us today to learn how we can support your compliance and documentation needs with expert guidance and industry insight.