Signing On to Hospice and the Election Statement

How do you sign up for hospice?

Somebody makes a phone call. That is the whole beginning. A patient, a family member, a physician, or a hospital social worker can call a hospice and ask for an information visit, and nothing about that call commits anyone to anything 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare and Hospice Benefits: Getting Started (CMS Product No. 11361).How a person starts hospice, that a hospice can be contacted directly for an information visit, the composition of the interdisciplinary hospice team, and the comfort-focused rather than curative goal of hospice care.. Two things afterward turn a conversation into enrollment: a physician certifies that the illness is terminal, and the patient signs an election statement choosing one particular hospice to deliver the benefit 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election..

Between those events sits an admission visit. A nurse comes to wherever the person already is — a house, a hospital room, a nursing facility — reads the record, examines the patient, and describes what the weeks ahead are likely to hold. The team that follows is interdisciplinary by design: nurses, aides, a social worker, a chaplain, a medical director, trained volunteers, and a plan of care organized around comfort rather than cure 1Ref 1Centers for Medicare & Medicaid Services (2024).Medicare and Hospice Benefits: Getting Started (CMS Product No. 11361).How a person starts hospice, that a hospice can be contacted directly for an information visit, the composition of the interdisciplinary hospice team, and the comfort-focused rather than curative goal of hospice care..

That visit is also an interview running the other direction. The hospice admission questions worth asking are the ones about nights and weekends, because nights and weekends are when a hospice is either present or absent.

Who certifies, and what they are certifying

Two physicians sign the first certification: the hospice medical director or a physician on the hospice's interdisciplinary group, and the patient's own attending physician if the patient has one 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.. What they attest to is a prognosis rather than a diagnosis — that the illness, allowed to run its normal course, would be expected to end life within about six months.

The reasoning behind that judgment is published. Medicare's coverage determination for hospice sets out non-disease-specific markers of decline — falling function, falling nutritional intake, the accumulating weight of other conditions — alongside disease-specific guidance, and it treats all of it as documentation that supports a prognosis rather than as a set of thresholds a patient has to cross 3Ref 3Centers for Medicare & Medicaid Services (Medicare Administrative Contractor LCD) (2023).Local Coverage Determination (LCD): Hospice - Determining Terminal Status (L33393).That Medicare's coverage determination sets out non-disease-specific criteria (functional and nutritional decline, comorbid conditions) alongside disease-specific guidance as documentation supporting a prognosis of six months or less, and that those disease-specific markers are guidance rather than absolute cutoffs..

Hospice is covered under Part A, Medicare's hospital insurance 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.. Original Medicare pays hospice. And nobody is asked to predict a date: a patient who lives past six months is recertified for another benefit period rather than discharged for having been wrong 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election..

What the hospice election statement says

The election statement is one page, and it is the moment the benefit begins. It is not a consent for treatment and it is not an advance directive. It is an election in the Medicare sense: a choice of who will deliver a defined benefit, starting on a stated date. Medicare specifies what must appear on it 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.:

• The particular hospice that will provide care, chosen by the patient.
• The attending physician, if the patient has one, with a written acknowledgment that the choice of that physician was the patient's own.
• An acknowledgment that the patient has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the terminal illness and its related conditions.
• An acknowledgment that certain Medicare services are waived by making the election.
• The effective date.
• The signature of the patient, or of the person authorized to sign for them.

The statement also carries two rights people rarely notice. One is the right to ask for an addendum listing the conditions, items, services, and drugs the hospice has determined are unrelated to the terminal illness and therefore not covered under the benefit. The other is the right to an immediate independent review if the patient disagrees with a decision the hospice has made 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.. Both exist because the election waives something real. It is fair to know exactly what.

What signing waives, and what it leaves untouched

Electing hospice means stopping curative treatment for the terminal illness — the chemotherapy intended to shrink the tumor, the dialysis intended to replace a kidney if kidney failure is the illness that is ending life. Medicare's hospice benefit covers care aimed at comfort for that illness and for the conditions related to it 4Ref 4Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.That electing hospice means curative treatment for the terminal illness stops; that Medicare continues to cover care for health problems unrelated to the terminal illness; and that room and board is generally not covered by the hospice benefit.. Waiving curative treatment for the terminal illness is the trade the whole benefit is built on.

What is not waived is the rest of medicine. Regular Medicare and hospice run alongside one another, and Medicare continues to pay for care of health problems that are not part of the terminal illness 4Ref 4Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.That electing hospice means curative treatment for the terminal illness stops; that Medicare continues to cover care for health problems unrelated to the terminal illness; and that room and board is generally not covered by the hospice benefit.. Hospice does not end Medicare. Someone enrolled for heart failure who breaks a wrist still gets the wrist treated, billed the ordinary way.

Two other lines deserve reading before the pen moves. Room and board is generally not covered by the hospice benefit 4Ref 4Centers for Medicare & Medicaid Services (2024).Hospice Care Coverage.That electing hospice means curative treatment for the terminal illness stops; that Medicare continues to cover care for health problems unrelated to the terminal illness; and that room and board is generally not covered by the hospice benefit., which matters enormously to any family weighing a facility. And it is the hospice that determines which conditions count as related to the terminal illness — which is exactly the determination the addendum was created to make visible 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election..

When hospice starts: the effective date

The election takes effect on the date written on the statement. That date can be the day the statement is signed, and it cannot be earlier than the day of the election itself 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.. There is no processing queue, no Medicare approval to wait on, no requirement that a hospital discharge happen first. Asked plainly, how quickly can hospice start is a question about an agency's staffing, not about the benefit's paperwork.

Everything else varies. Whether a nurse arrives that evening, whether medications are delivered before dark, whether a hospital bed is in the living room by the time the transport home is over — those depend on the hospice, the hour, and the day of the week. Same-day admission is a fair thing to ask about directly: how many hours from this phone call to a nurse at the bedside, tonight, and what changes if tonight is a Saturday.

Palliative care does not require this signature

Palliative care and hospice are not two names for one thing, and only one of them requires an election. Palliative care is specialized care for the symptoms and the stress of a serious illness, and it can be given at any stage of that illness, alongside treatment intended to cure 5Ref 5National Institute on Aging (NIH) (2024).What Are Palliative Care and Hospice Care?.That palliative care can be given at any stage of a serious illness alongside treatment intended to cure, and that hospice is the form of palliative care used near the end of life once curative treatment for the terminal illness has stopped.. Hospice is the form of palliative care used near the end of life, when curative treatment for the terminal illness has stopped 5Ref 5National Institute on Aging (NIH) (2024).What Are Palliative Care and Hospice Care?.That palliative care can be given at any stage of a serious illness alongside treatment intended to cure, and that hospice is the form of palliative care used near the end of life once curative treatment for the terminal illness has stopped..

The distinction is palliative vs curative intent. It is about the goal of a treatment, not about the seriousness of the disease. Nothing in palliative care asks a patient to surrender an intent, and nothing in hospice asks a patient to surrender comfort.

For a person who is not ready, and for a family that cannot yet say the word out loud, palliative care is the door that opens without a signature.

Signing late is the common story

Most of the regret about hospice turns out to be regret about timing. Among Medicare beneficiaries who died in 2000, 2005, and 2009, hospice use rose — and alongside it rose intensive-care use near the end of life and burdensome transitions between care settings in the final days, including hospice enrollments that began only shortly before death 6Ref 6Teno JM, Gozalo PL, Bynum JPW, et al. (2013).Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009.That among Medicare decedents in 2000, 2005, and 2009 hospice use rose while intensive-care use near death and burdensome late transitions between care settings also rose, including very short hospice enrollments beginning shortly before death..

An enrollment measured in days delivers almost none of what the benefit contains. The medications are still being adjusted. The aide has visited twice. The chaplain has not come. The family has not slept, and the thing hospice is genuinely best at — teaching a household how to care for someone at home, and answering the telephone at three in the morning — takes longer than a weekend to arrive.

Signing early forecloses nothing. The election can be revoked.

If you change your mind

The election is reversible, and it is reversible by the patient. Revoking hospice requires a signed statement giving the date the revocation takes effect; a telephone call does not accomplish it, and a relative's preference does not accomplish it 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.. From the effective date of the revocation, standard Medicare coverage for the terminal illness resumes.

Leaving hospice and coming back later is an ordinary path rather than a failure of nerve. No waiting period stands between a revocation and a new election, and no penalty attaches to having left 2Ref 2Centers for Medicare & Medicaid Services (2024).Medicare Benefit Policy Manual, Chapter 9 - Coverage of Hospice Services Under Hospital Insurance.The technical mechanics of electing hospice: certification of terminal illness by the hospice medical director and the attending physician, the required contents and effective date of the election statement, coverage of hospice under Part A hospital insurance, the benefit-period and recertification structure, and the requirement that revocation be made in a signed written statement with no waiting period before re-election.. People revoke to try a treatment, to have a surgery, to be admitted under a different benefit, and then they return.

The hospice revocation statement and the election statement are mirror images of each other: a date, a signature, and a choice that belongs to exactly one person.