Hospice Election Statement Addendum 2026: The Compliance Checklist Before the Grace Period Ends

What Changed on October 1, 2026

Until this fall, most hospices treated the election statement addendum as a document they produced only when a patient or representative asked for it. Many agencies received few or no requests, so the form lived in a folder and rarely touched the admission workflow.

The FY2027 Hospice Final Rule changes that. For hospice elections on or after October 1, 2026, the hospice must provide the addendum to every Medicare beneficiary, whether or not anyone requests it. That moves the addendum from an exception process into the core admission packet, alongside the election statement itself.

For elections that took effect before October 1, the new every-election requirement does not reach back. In practice, many agencies are choosing to apply the new process to current patients when a plan-of-care change creates a natural moment to do so, because it keeps one workflow instead of two.

Why CMS Made the Change

CMS pointed to dramatic increases in non-hospice spending for hospice patients between FY2020 and FY2024. In plain terms, Medicare kept paying other providers for care delivered to people already enrolled in hospice. Some of that spending is appropriate, because a patient can have conditions that are genuinely unrelated to the terminal illness. Some of it suggests that care which should sit inside the hospice benefit is being billed elsewhere.

The addendum is CMS's way of making the hospice put its related and unrelated decisions on paper, in plain language, at the start of care. When the reasoning is written down, patients understand what is covered, outside providers know where to send bills, and reviewers can test whether the decisions hold up. This same focus on related versus unrelated care drives the new Hospice SSVI.

What the Addendum Must Contain

The CMS model addendum is the safest starting point. Whatever format you use, each required element should be easy for a reviewer to find.

If a patient has no unrelated conditions, items, services, or drugs, the addendum should say so clearly rather than being skipped. A blank or missing form reads as a missed step, not as a clinical decision.

The Two Deadlines That Matter

Within 5 days of the election effective date

The addendum must be provided in writing within the first 5 days of the election effective date and filed with the election statement. Build the clock from the effective date, not from the day intake paperwork is scanned. If your admission visit happens late in that window, the addendum should be completed at the visit, not queued for later.

Within 3 days of a qualifying plan-of-care change

If a plan-of-care change affects the related or unrelated determinations, the hospice must provide an updated addendum within 3 days and file it. Common triggers include a new diagnosis, a medication the hospice now considers related, or a decision to stop covering an item. The hard part is not writing the update. It is noticing that a change qualifies. Your IDG meeting template should include a direct question: did anything today change what we consider related or unrelated?

What the Grace Period Protects, and What It Does Not

CMS announced enforcement discretion for the first quarter of the new requirement. From October 1 to December 31, 2026, MACs will not deny claims solely because the addendum is missing or incomplete, and they will focus on education.

That protection is narrow. It covers denials based only on the addendum. It does not excuse other documentation problems in the same record, and it does not change the requirement itself, which is already in effect. After December 31, expect full scrutiny of the addendum during medical review. Treat the next 90 days as a paid rehearsal: every gap you find now is a gap that will not show up in a reviewer's findings later. Our 90-day readiness plan breaks this into monthly steps.

How Addendum Gaps Show Up in ADRs and Medical Review

When a reviewer requests records for a hospice claim, the election statement is one of the first documents examined. Going forward, a reviewer can reasonably expect to find the addendum filed beside it. The following patterns are the ones most likely to draw attention:

Each of these is fixable before an ADR arrives. If an ADR is already open, assemble the election statement and addendum together, confirm dates line up, and track the response with a clear owner and deadline. Missed ADR deadlines create avoidable denials, which we cover in our guide to denial code 56900.

Writing Plain-Language Reasons That Hold Up

The reasons section is where most addendums are weakest. A reason should explain, in words a family member understands, why the hospice decided a condition, item, service, or drug is not related to the terminal illness and related conditions. It should be specific to the patient and consistent with the rest of the record.

Compare two versions. A weak reason says: "Not related to hospice diagnosis." A stronger reason says: "This medication treats a long-standing thyroid condition that is stable and is not contributing to the illness your hospice care is focused on." The second version names the condition, explains the clinical logic, and gives the patient something to discuss or dispute.

A few habits help:

Strong reasons protect the patient relationship as much as the claim. Families who understand why something is not covered are less likely to be surprised by an outside bill, and less likely to feel misled when they learn about it.

A quick test: pick three recent addendums and read only the reasons section aloud to a colleague who does not work in clinical care. If they cannot explain back why each item is not covered, the reasons need work.

The Full Compliance Checklist

Use these 11 items as your working standard. The downloadable version contains the same list in a printable format.

Item 8 is the one agencies miss most often. Older packets that promise the addendum on request now contradict your actual obligation, and a reviewer reading them may question whether staff know the rule changed.

Who Owns What

The addendum touches several teams. Assign each step to a named role so nothing depends on goodwill.

Agencies in PPEO states face prepayment review on every claim, which raises the cost of any missing document. If you operate in Arizona, California, Nevada, Texas, Georgia, or Ohio, read our PPEO hospice guide and our breakdown of the 2026 hospice moratorium.