Hospice Election and Benefit Periods: Billing the Right Period

How the hospice election works

A Medicare beneficiary elects the hospice benefit by choosing palliative care for a terminal illness and waiving curative treatment for that condition. The election is filed as a Notice of Election, which Medicare requires within five calendar days of the start of care. A late Notice of Election shifts financial responsibility for the days before it was filed onto the agency, so the election is both a clinical decision and a billing deadline.

The election also starts the benefit-period clock. From that date forward, the patient's hospice coverage is measured in defined periods, and the agency's claims have to line up with them. The rules governing hospice coverage live in 42 CFR Part 418.

The benefit-period structure

Medicare structures the hospice benefit as two 90-day periods followed by an unlimited number of 60-day periods. A patient can remain on hospice indefinitely as long as a physician recertifies, before each new period, that the terminal prognosis still holds. There is no lifetime limit on the number of 60-day periods.

Recertification is what carries a patient from one period into the next, and it is where billable days are won or lost. Beginning with the third period — the first 60-day period — the rules also require a face-to-face encounter with a hospice physician or nurse practitioner. A missed or late recertification can make days in the new period unbillable even when the care itself was appropriate.

Prior elections and transfers between hospices

The benefit-period clock belongs to the patient, not to any one agency. A beneficiary who elected hospice before — with another provider, or with yours in an earlier episode — does not reset to a first 90-day period on admission to you. They resume where their history left off, which may be well into the 60-day periods.

A transfer is the clearest case. When a patient moves from one hospice to another within a benefit period, the receiving agency continues the same period rather than starting a new one. Bill as though the clock started at your admission, and the period on the claim will not match what Medicare already holds for that beneficiary.

Why the wrong period or a missed election causes rejections

Medicare matches each hospice claim against the beneficiary's election and benefit-period history. When the period billed does not match the period on record — because a prior election was missed, a transfer was treated as a new start, or a recertification gap went unnoticed — the claim is rejected, and the correction happens after the fact, when payment is already delayed.

These are not usually clinical errors; the care may be entirely appropriate. They are history errors, and they are hard to catch at the point of billing because the information that would reveal them — the patient's prior elections and current period — lives outside the chart in front of the biller.

Checking the history before you bill

The way to keep these errors out of your claims is to establish the patient's coverage and benefit-period history at the eligibility check, not at billing. EligibilityIQ confirms Medicare coverage, benefit periods, and prior hospice elections, and surfaces that benefit-period and prior-election context with every eligibility check — so the period you bill reflects the history Medicare already holds.

EligibilityIQ surfaces and flags that context; it does not replace the clinician and coder judgment that governs certification and the election decision, and it does not guarantee a claim will be paid. What it does is put the prior-election and benefit-period information in front of the team before the claim is built, where it can still change the outcome.

Frequently asked questions

How do hospices avoid billing the wrong benefit period or missing a prior hospice election?

The reliable approach is to confirm the patient's benefit-period history and any prior elections at the eligibility check, before the claim is built, rather than discovering a mismatch after a rejection. EligibilityIQ confirms Medicare coverage, benefit periods, and prior hospice elections and surfaces that context with each check, so the period on the claim reflects the history Medicare already has on file.

What are the Medicare hospice benefit periods?

Medicare provides two 90-day benefit periods followed by an unlimited number of 60-day periods. A patient can stay on hospice indefinitely as long as a physician recertifies the terminal prognosis before each new period, and the third period onward also requires a face-to-face encounter.

Does a patient who transfers between hospices start a new benefit period?

No. The benefit-period clock follows the patient, so a transfer continues the same period rather than starting a new one. Billing a transferred patient as a first period is a common cause of rejection, which is why confirming prior elections at the eligibility check — as EligibilityIQ does — matters.

What is the deadline for filing a hospice Notice of Election?

Medicare requires the Notice of Election to be filed within five calendar days of the start of hospice care. A late notice shifts responsibility for the days before it was filed onto the agency, so the election deadline is as much a billing matter as a clinical one.