(Medicare Benefit Policy Manual)

10. The date the hospice furnished the addendum.  The date furnished must be within the required timeframe (that is, 3 or 5 days of the beneficiary or representative request, depending on when such request was made).   Example:  Mr. Brown elects hospice  on December 1st and requests the addendum on December 3rd.  The hospice must provide this information, in writing, to Mr. Brown within 5 days of the request.  Therefore, the addendum would be required to be provided to Mr. Brown on or before December 8th.   Example:  Mrs. Smiths effective date of her hospice election was November 1st, but she did not request the election statement addendum on that date.  On December 4th, Mrs. Smith requests the election statement addendum.  Since Mrs. Smith requested the election statement addendum during the course of hospice care (that is, after the first 5 days of the hospice election date), the hospice must provide this information, in writing, within 3 days of her request.  Therefore, the addendum would be required to be provided to Mrs. Smith on or before December 7th.    Example:  Miss Jones requested the election statement addendum on May 1st, the effective date of her initial hospice election.  Miss Jones died on May 3rd.  Because Miss Jones died within the first 5 days from the start of hospice care and before the hospice was able to furnish the addendum, the addendum would not be required to be furnished after Miss Jones has died, and this condition for payment would be  considered met.   20.2.1.3- Hospice Notice of Election  (Rev. 10437, Issued: 11- 06-20, Effective: 10 -01-20, Implementation: 12- 09-20)  Upon electing the Medicare hospice benefit, the beneficiary waives the right to Medicare payment for any Medicare services related to the terminal illness and related conditions (i.e., the patients prognosis) during a hospice election, except when provide d by, or under arrangement by, the designated hospice or individuals attending physician if he or she is not employed by the designated hospice (42 CFR 418.24 (d)).   In order to establish the hospice election in the Medicare claims processing system, the hospice must submit a Notice of Election (NOE) as described in chapter 11, section 20.1.1 of the Medicare Claims Processing Manual (Pub.100- 04).  Prompt filing of the hospice NOE with the Medicare contractor is required to properly enforce this waiver and prevent inappropriate payments to non- hospice providers.  The effective date of hospice election is the same as the hospice admission date.   Timely -filed hospice NOEs shall be filed within 5 calendar days after the hospice admission date.  A timely -filed NOE is one that is submitted to and accepted by the Medicare contractor within 5 calendar days after the hospice election.   The practical meaning of submitted to and accepted by the Medicare contractor is that the NOE was not returned to the provider for correction.   Example: The date of hospice election is October 1st.  A timely -filed NOE would be submitted and accepted by the Medicare contractor on or before October 6th.  In instances where a NOE is not timely -filed, Medicare shall not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor.  These days shall be provider liable, and the provider shall not bill the beneficiary for them.  Example: The date of hospice election is October 1st. The NOE was not submitted and accepted by the Medicare contractor until October 10th.  Provider liable days would be October 1st through October 9th.  There may be some circumstances that may be beyond the control of the hospice where it may not be possible to timely -file the NOE within 5 calendar days after the effective date of election or timely -file the Notice of Termination or Revocation (NOTR)  (see section 20.2.4 -  Hospice Notice of Termination or Revocation) within 5 calendar days after the effective date of a beneficiarys discharge or revocation.  Therefore, the regulations do allow for exceptions.  There are four circumstances that may qualify t he hospice for an exception to the consequences of filing the NOE more than 5 calendar days after the effective date of election.  These exceptional circumstances are as follows:   1.  Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospices ability to operate;   2.  An event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice;   3.  A newly Medicare -certified hospice that is notified of certification after the Medicare certification date, or is awaiting its user ID from its Medicare contractor; or,   4.  Other circumstances determined by CMS to be beyond the control of the hospice.  If one of the four circumstances described above prevents a hospice from timely- filing its NOE, the hospice must document the circumstance to support a request for an exception, which would waive the consequences of filing the NOE late.  Using that documentation, the hospices Medicare contractor will determine if a circumstance encountered by a hospice qualifies for an exception to the consequences for filing an NOE more than 5 calendar days after the effective date of election.  If the request for an exception is denied, the Medicare contractor will retain the decision of the denial.  Hospices retain their usual appeal rights on the claim for payment.  A retroactive Medicare entitlement qualifies as one of the exceptions to a timely -filed NOE as this would be a circumstance that is beyond the hospices control.  An individual must be entitled to Medicare Part A in order to be eligible to receive services under the Medicare hospice benefit and an individual who receives retroactive Medicare entitlement is entitled to Medicare hospice services effective on the first day of that entitlement.  In the event of retroactive Medicare entitlement, the hospice would submit a request for an exception, which would waive the consequences of filing the NOE late. To receive an exception, the individual must  meet eligibility requirements under the Medicare hospice benefit and must have elected to receive services under the Medicare hospice benefit. Therefore, the hospice must be able to provide the following documentation to Medicare contractors and/or CMS, if requested:   (1) Proof of retroactive Medicare entitlement;  (2) The certification of terminal illness that meets the criteria set forth in section 20.1; and  (3) The hospice election statement that meets the criteria set forth in section 20.2.1.1.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims for requirements for NOE submission, reporting provider -liable days, and qualifying circumstances for a request for exception.  20.2.2 - Hospice Revocation  (Rev. 209, Issued: 05- 08-15, Effective: 10 -01-14, Implementation: 05- 04-15)  An individual or representative may revoke the election of hospice care at any time in writing; however a hospice cannot revoke a patients election.  To revoke the election of hospice care, the individual must file a document with the hospice that includes:    A signed statement that the individual revokes the election for Medicare coverage of hospice care for the remainder of that election period, and    The effective date of that revocation.  An individual may not designate an effective date earlier than the date that the revocation is made.   Note that a verbal revocation of benefits is NOT acceptable.  The individual forfeits hospice coverage for any remaining days in that election period.   Upon revoking the election of Medicare coverage of hospice care for a particular election period, the individual is no longer covered under the Medicare hospice benefit, and resumes Medicare coverage of the benefits waived when hospice care was elected.  A n individual may, at any time, elect to receive hospice coverage for any other hospice election periods that he or she is eligible to receive.   20.2.3 - Hospice Discharge  (Rev. 209, Issued: 05- 08-15, Effective: 10 -01-14, Implementation: 05- 04-15)  The hospice notifies the Medicare contractor of any discharge so that hospice services and billings are terminated as of that date.  Upon discharge, the patient loses the remaining days in the benefit period.  However, there is no increased cost to the beneficiary.  General coverage under Medicare is reinstated at the time the patient revokes the benefit or is discharged.   Once a hospice chooses to admit a Medicare beneficiary, it may not automatically or routinely discharge the beneficiary at its discretion, even if the care promises to be costly or inconvenient, or the State allows for discharge under State requirements.  The election of the hospice benefit is the beneficiarys choice rather than the hospices choice, and the hospice cannot revoke the beneficiarys election.  Neither should the hospice request or demand that the patient revoke his/her election.   Discharge from a hospice can occur as a result of one of the following:    The beneficiary decides to revoke the hospice benefit;    The beneficiary transfers to another hospice;    The beneficiary dies;    The beneficiary moves out of the geographic area that the hospice defines in its policies as its service area.  Some examples of moving out of the hospices service area include, but are not limited to, when a hospice patient moves to another part of the c ountry or when a hospice patient leaves the area for a vacation.  Another example would be when a hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which the hospice does not have a contract, and the hospice is unable to access the patient to provide hospice services.  In this example, Medicares expectation is that the hospice provider would consider the amount of time the patient is in that facility and the effect on the plan of care before making a determination that discharging the patient from the hospice is appropriate;    The beneficiarys condition improves and he/she is no longer considered terminally ill.  In this situation, the hospice will be unable to recertify the patient.  The beneficiary can ask the Quality Improvement Organization (QIO) for an expedited review of the discharge (see Pub. 100- 04, chapter 30, section 260 for more information); or    Discharge for cause: There may be extraordinary circumstances in which a hospice would be unable to continue to provide hospice care to a patient.  These situations would include issues where patient safety or hospice staff safety is compromised.  When a hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the  patient or the ability of the hospice to operate effectively is seriously impaired, the hospice can consider discharge for cause.  The hospice must do the following before it seeks to discharge a patient for cause:   o Advise the patient that a discharge for cause is being considered;   o Make a serious effort to resolve the problem(s) presented by the patient's behavior or situation;   o Ascertain that the patient's proposed discharge is not due to the patient's use of necessary hospice services; and   o Document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the patients medical records.   The hospice must notify the Medicare contractor and State Survey Agency of the circumstances surrounding the impending discharge.  The hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult Protective Services) as appropriate.   Discharge order :  Prior to discharging a patient for any reason other than a patient revocation, transfer, or death, the hospice must obtain a written physician's discharge order from the hospice medical director.  If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.  Effect of discharge:  An individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice    Is no longer covered under Medicare for hospice care;   Resumes Medicare coverage of the benefits waived; and   May at any time elect to receive hospice care if he or she is again eligible to receive the benefit.   Discharge planning:  The hospice must have in place a discharge planning process that takes into account the prospect that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill.  The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill.