evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
6. 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.  This clinical explanation must be accompanied by a general statement that the decision as to whether or not conditions, items, services, and drugs are related 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.   7. References to any relevant clinical practice, policy, or coverage guidelines   8. Information on the following:   i. Purpose of Addendum. The purpose of the addendum is to notify the individual (or representative), in writing, of those conditions, items, services, and drugs the hospice will not be covering because the hospice has determined they are unrelated to the indi vidual's terminal illness and related conditions.   ii. Right to Immediate Advocacy. The addendum must include language 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.   9. Name and signature of the individual (or representative) and date signed, along with a statement that signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily the individual's (or repres entative's) agreement with the hospice's determinations.  If the individual (or representative) refuses to sign a requested addendum, the hospice must document why (on the addendum itself) and it would become a part of the medical record.    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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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,
(Medicare Benefit Policy Manual)
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)
(Medicare Benefit Policy Manual)
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;
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
Once a patient is no longer considered terminally ill with a life expectancy of 6 months or less if the disease runs its normal course, Medicare coverage and payment for hospice care should cease.  Medicare does not expect that a discharge would be the res ult of a single moment that does not allow time for some post -discharge planning.  Rather, it would be expected that the hospices interdisciplinary group is following the patient, and if there are indications of improvement in the individuals condition s uch that hospice may soon no longer be appropriate, then planning should begin.  If the patient seems to be stabilizing, and the disease progression has halted, then it could be the time to begin preparing the patient for alternative care.  Discharge planning should be a process, and planning should begin before the date of discharge.   In some cases, the hospice must provide Advanced Beneficiary Notification (ABN) or a Notice of Medicare Non -Coverage (NOMNC) to patients who are being discharged.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 30 Financial Liability Protecti ons, Section 50.15.3.1, for information on these requirements.   20.2.4 - Hospice Notice of Termination or Revocation  (Rev. 209, Issued: 05- 08-15, Effective: 10 -01-14, Implementation: 05- 04-15)  Upon discharge or revocation of hospice care, the beneficiary immediately resumes the Medicare coverage that had previously been waived by the hospice election.  As such, hospices should record the beneficiarys discharge or revocation in the claims proces sing system promptly.   If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the election of hospice care, the hospice shall submit a timely -filed Notice of Termination/Revocation (NOTR) unless the hospice has already filed a final claim.  A timely -filed NOTR is a NOTR that is submitted to and accepted by the Medicare contractor within 5 calendar days after the effective date of discharge or revocation. Hospices continue to have 12 months from the date of service in which to file their claims.
(Medicare Benefit Policy Manual)
See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims for requirements for NOTR submission.  20.3 - Election by Skilled Nursing Facility (SNF) and Nursing Facilities (NFs) Residents and Dually Eligible Beneficiaries  (Rev. 1, 10- 01-03) HO- 204.2  A Medicare beneficiary who resides in an SNF or NF may elect the hospice benefit if:    The residential care is paid for by the beneficiary; or    The beneficiary is eligible for Medicaid and the facility is being reimbursed for the beneficiarys care by Medicaid, and    The hospice and the facility have a written agreement under which the hospice takes full responsibility for the professional management of the individuals hospice care and the facility agrees to provide room and board to the individual.  A beneficiary could be in a SNF under the SNF benefit for a condition unrelated to the terminal condition and simultaneously be receiving hospice for the terminal condition.  The State Medicaid Agency pays the hospice the daily amount allowed by the State for room and board while the patient is receiving hospice care, and the hospice pays the facility.  Room and board services include the performance of personal care services, assistance in activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of a residents room, and supervising and assisting in the use of durable medical equipment and prescribed therapies.  Whenever Medicaid is involved, the hospice sends a copy of the election form to the State Medicaid Agency at the time of election, and also notifies this agency when the patient is no longer receiving hospice care.   In States that offer the hospice benefit under the Medicaid program, dually eligible beneficiaries must elect the benefit under both programs at once.   20.4 - Election by Managed Care Enrollees  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)
(Medicare Benefit Policy Manual)
20.4 - Election by Managed Care Enrollees  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  A managed care enrollee may elect the hospice benefit.  After the hospice election, Medicare pays the hospice for hospice services and pays for services of the managed care attending physician, who may be a nurse practitioner, (as defined in section 20.1 of this chapter) and services not related to the patients terminal illness, through the fee -for-service system.  (See 42 CFR 417.531 and 417.585.)  Once under a hospice election, a managed care patient may also choose to use a provider outside of his or he r managed care organization for care unrelated to the terminal illness or related conditions, or as the attending physician.  See Pub. 100- 04, Medicare Claims Processing Manual, chapter 11, section 40 for requirements for physician billing.  Once a managed care enrollee has elected hospice, all his or her Medicare benefits revert to fee- for-service, though the enrollee still remains on managed care for any additional benefits provided by his or her managed care plan, such as dental or vision c overage.  The Medicare hospice benefit, through fee -for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.  During the election, fee- for-service Medicare also covers attending physician ser vices and all care unrelated  to the terminal illness.  Upon discharge or revocation, fee -for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive.  At the start of the month following revocat ion or discharge, all billing and coverage revert back to the managed care plan (see Pub 100- 04, Medicare Claims Processing Manual, chapter 11, 30.4).   30 - Coinsurance  (Rev. 1, 10- 01-03) A3-3142   Hospices may charge individuals for the applicable coinsurance amounts.  An individual who has elected hospice care is liable for the following coinsurance payments.  30.1 - Drugs and Biologicals Coinsurance  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)