Recent Rules and Guidance Address Transparency in Hospice Coverage

Effective for hospice elections beginning on or after October 1, 2020, Medicare beneficiaries are entitled to greater transparency about the conditions, items, services, and drugs that a provider does not believe are covered under the hospice benefit and will not provide.

In its FY 2020 Hospice Wage Index and Payment Rate Update final rule (84 FR 38520), the Medicare federal agency addressed coverage vulnerabilities in the hospice benefit by requiring (1) additional information on hospice election statements, and (2) provision of a hospice election statement addendum upon the beneficiary’s (or representative’s) request.  The agency recently issued guidance concerning these changes. https://www.cms.gov/files/document/mm12015.pdf

In addition to the existing content requirements at 42 CFR § 418.24(b), hospice election statements must now include:

• Information about beneficiary cost-sharing for hospice services;
• A statement indicating that services unrelated to the terminal illness and related conditions are “exceptional and unusual and hospice should be providing virtually all care needed by the individual who has elected hospice”;
• Notification of the individual’s (or representative’s) right to receive an election statement addendum that lists and explains the conditions, items, services, and drugs that the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and will not be covered by the hospice; and
• Information that immediate advocacy is available through the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) if the beneficiary (or representative) disagrees with the hospice’s determination.

Upon request by the individual (or representative), the individual’s non-hospice provider, or a Medicare contractor, hospice providers are required to furnish an addendum to the election statement, titled “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” The addendum must contain a written clinical explanation, in language the individual (or representative) can understand, as to why the identified conditions, items, services, and drugs are considered unrelated to the individual’s terminal illness and related conditions and not needed for pain or symptom management. 

The clinical explanation must be accompanied by a general statement that such determination is made for each patient and that the individual should share this clinical explanation with other health care providers from which they seek items, services, or drugs unrelated to their terminal illness and related conditions. The addendum must also reference any relevant clinical practice, policy, or coverage guidelines. Further, it must notify that immediate advocacy is available through the Medicare Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) if the individual (or representative) disagrees with the hospice’s determination.

Evidence of a signed addendum in the requesting beneficiary’s medical record would be a condition for payment of the hospice provider’s claim.  CMS has importantly clarified that a signed addendum is “only acknowledgement of receipt of the addendum (or its updates) and not necessarily the individual's (or representative's) agreement with the hospice's determinations.”  For more details about the new requirements, including timeframes for furnishing the addendum, refer to 42 C.F.R. § 418.24, the Medicare Benefits Policy Manual (Pub. 100-02) Chapter 9, or the agency’s recent guidance.  https://www.cms.gov/files/document/mm12015.pdf