Model Example of “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”

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Patient Name: 	 Patient MRN: 		
Hospice Agency Name: 		Date Furnished: 	
Purpose of Issuing this Notification
The purpose of this addendum is to notify you, as the Medicare beneficiary electing hospice care (or beneficiary representative), in writing, of those conditions, items, services, and drugs not covered by the hospice because the hospice has determined they are unrelated to your terminal illness and related conditions. For hospice elections beginning on or after October 1, 2026, the hospice must provide you, in writing, with this notification within the first 5 days of your hospice election start date. Your hospice must also file this information with your election statement to be available for you (or your representative), your non-hospice providers, and Medicare contractors. Additionally, within 3 days of the hospice making any changes to your plan of care that impact the addendum determinations, they must provide an updated written addendum to you (or your representative), if there are any changes to the non-covered items, services and drugs. The hospice must also file the updated addendum with your election statement so that these changes are communicated with to your non-hospice providers and Medicare contractors. 
Diagnoses Related to Terminal Illness and Related Conditions
1.	5.
2.	6.
3.	7.
4.	8.
Diagnoses Unrelated to Terminal Illness and Related Conditions
1.	5.
2.	6.
3.	7.
4.	8.
Items, Services, and Drugs Determined by Hospice to be Unrelated to Your Terminal Illness and Related Conditions (these items, services, and drugs will not be covered under the hospice benefit):












Note: The hospice makes the decision as to whether conditions, items, services, and drugs are related for each patient. As the beneficiary (or beneficiary representative), you should share this list and clinical explanation with other healthcare providers from which you seek items, services, or drugs, unrelated to your terminal illness and related conditions to assist in making
treatment decisions. The hospice should provide its reasons for non-coverage in language that you (or your representative) understand.
Right to Immediate Advocacy
As a Medicare beneficiary, you have the right to contact the Medicare Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) to request for Immediate Advocacy if you (or your representative) disagree with the decision of the hospice agency on items not covered because the hospice has determined they are unrelated to your terminal illness and related conditions.



Please visit this website to find the BFCC-QIO for your area: https://qioprogram.org/locate-your-qio or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Note: The 'date furnished' is defined as when the beneficiary (or representative) receives an addendum (or its updates), in writing, within 5 days of the effective date of election (or within 3 days of any updates made to the plan of care that impact the addendum determinations), not the date of the signature.

Signing this notification (or its updates) is only acknowledgement of receipt of this notification (or its updates) and does not constitute your agreement with the hospice’s determinations.

Signature of Beneficiary: 	

Signature of Beneficiary Representative (if beneficiary is unable to sign): 	
Date Signed: