You may hear a sentence that sounds final: “Hospice does not cover that.”
Do not try to settle the question from memory at the kitchen table. Ask for the coverage decision in writing. Medicare hospice paperwork has a specific place for it.
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The document is called the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. It is an addendum to the hospice election statement. It identifies what the hospice has determined is unrelated to the terminal illness and related conditions, and therefore will not be covered by the hospice benefit.
This paper does not tell you whether to continue, stop or change anything. It gives you something narrower and useful: the hospice’s coverage position, item by item, with its reason.
Ask for the named document
Say, “Please give me our current Patient Notification of Hospice Non-Covered Items, Services, and Drugs.” If the hospice says there is nothing on the list, ask for the paperwork that shows that.
Do not settle for a general benefits brochure or a handwritten note saying “not covered.” Under the federal hospice rule, the addendum is meant to identify the relevant conditions and the particular items, services or drugs the hospice will not cover. It must also include an explanation, in language you can understand, of why the hospice considers them unrelated.
When the document arrives, check that it has:
Your family member’s name and the hospice’s name.
The date the document was furnished.
The conditions the hospice identifies as related to the terminal illness.
The conditions it identifies as unrelated.
Each non-covered item, service or drug named specifically.
A reason for each non-coverage determination.
Information about the Medicare quality improvement organization that can provide immediate advocacy if you disagree.
If a line says only “unrelated,” ask the hospice to explain the reason in words you can follow. You are not asking the hospice to interpret a symptom. You are asking it to complete the coverage explanation that belongs with its decision.
Match the paper to the thing in front of you
A broad category may not settle a specific bill. Put the addendum beside the medicine label, supply order, appointment notice or invoice.
Then ask the hospice:
Is this exact item on the non-covered list?
Is the hospice saying the whole service is unrelated, or only part of it?
Who made the coverage determination?
Has the plan of care changed since this addendum was furnished?
Does the addendum need to be updated before we arrange or pay for this?
Write down the name of the person answering, the time of the call and what that person said. Keep the answer with the addendum. A phone assurance is easier to lose than a page attached to the bill.
A signature is not the same as agreement
The federal hospice guidance says that signing the addendum acknowledges receipt. It does not necessarily mean that you agree with the hospice’s determinations.
Before signing, read the title and every listed item. Ask for a copy of the completed document, including the signature page. If you disagree, say so plainly and ask where the disagreement will be recorded. Do not add your own wording to a form unless the hospice confirms how it will preserve that note in the record.
Keep this addendum with the election statement, not in a loose stack of visit papers. The two documents belong together.
Do not treat the first copy as permanent
The list may change when the plan of care changes. If the hospice changes a determination about a condition, item, service or drug, ask for the updated addendum and replace the working copy in your folder.
Compare the old and new versions before filing either one away. Mark what was added, removed or rewritten. Ask when the changed determination began and which pending orders or bills it affects.
Keep the earlier version. It may help you show what the paperwork said when an item was ordered or received.
Before you buy or schedule outside hospice
Medicare tells families to contact the hospice before obtaining services related to the terminal illness and related conditions. That call matters because care arranged outside the hospice may leave the family responsible for the cost.
Before agreeing to an outside purchase or appointment, ask four offices four separate questions:
The hospice: Is this exact item or service covered by hospice? If not, where is it listed on the addendum?
The outside provider: Have you spoken with the hospice, and whom do you expect to bill?
The supplier or pharmacy: Are you billing the hospice, Medicare, another insurer or the family?
The insurer: What paperwork is required when hospice has classified the condition or item as unrelated?
Ask for written estimates, billing notices or coverage explanations that each office can provide. A quote is not the same as a coverage decision, and a coverage decision is not a promise that another payer will pay. Keep each document under its own heading.
If the paperwork and the bill do not match
Do not begin by arguing about the whole hospice benefit. Name the mismatch.
You can say, “The addendum does not list this item,” or, “The reason on the bill is different from the reason on the addendum.” Then ask the hospice billing contact and the clinical team to review the same documents.
If you disagree with the hospice’s determination, look on the addendum or election statement for the contact information for the Beneficiary and Family Centered Care Quality Improvement Organization. Medicare describes immediate advocacy as an available route for disputes about these non-coverage determinations.
For a complaint about a hospice provider in Missouri, you can also ask Missouri’s health department which complaint process applies. Keep that separate from a billing appeal. A complaint, an advocacy request and an insurance claim may be handled by different offices.
Build one small coverage file
You do not need a perfect filing system. Use one folder with:
The hospice election statement.
The current non-covered items addendum.
Every earlier version of the addendum.
The current plan of care pages the hospice has given you.
Orders, labels and appointment notices connected to disputed items.
Quotes, invoices, receipts and insurer notices.
A call log with names and answers.
Put the current addendum on top. If someone calls while you are tired, you will have the hospice’s written position in front of you.
The point is not to turn you into a billing specialist. It is to keep one spoken “not covered” from becoming a purchase, a missed service or a bill before anyone has shown you what the hospice paperwork actually says.
The Medicare guidance, federal hospice rule and other source materials behind this guide are collected on the Sources page. For the larger division between scheduled hospice visits and the hours the household still covers, see The Hours Between Hospice Visits.