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September 30, 2026

CMS Model Examples of the Hospice Election Statement and Election Statement Addendum

Centers for Medicare & Medicaid Services (CMS) has published model examples of the hospice election statement and election statement addendum in the download section of the HospiceExternal Website spotlight webpage. The model examples are not mandatory to use, as each hospice may design and print their own forms, but are suggested to ensure compliance of the information required on each form.

In August 2026, CMS updated the model hospice election statement and election statement to comply with the new requirement beginning on October 1, 2026, when the election statement addendum becomes mandatory for all those electing hospice on or after that date and not just those who request the addendum. This requirement may hold hospices more accountable for the items, services, and drugs they are required to provide. The addendum also will provide needed information to non-hospice providers for claims submission. Hospices shall ensure their election statements comply with this new requirement.

The CMS and HHH Medicare Administrative Contractors (MACs) highly recommend hospice agencies compare or model their forms to the examples CMS has provided. Non-compliant hospice election statements continue to be identified as a top denial reason by review contractors, including the MAC's Targeted Probe and Educate process.

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