15.1 Medicare Hospice Benefit and Conditions of Participation
Key Takeaways
- Medicare hospice Conditions of Participation are codified at 42 CFR Part 418 and are the federal regulatory floor for Medicare-certified hospices.
- Core services under 42 CFR 418.64 include nursing, medical social services, physician services, and counseling; the hospice must routinely provide substantially all core services by hospice employees and cannot delegate away responsibility for the care.
- The interdisciplinary group must include a physician, a registered nurse, a social worker or marriage and family therapist or mental health counselor, and a pastoral or other counselor; a designated IDG registered nurse coordinates care.
- The hospice registered nurse completes the initial assessment within 48 hours of election; the interdisciplinary group completes the comprehensive assessment within 5 calendar days; the plan of care is reviewed at least every 15 calendar days.
- CMS hospice quality reporting continues through the Hospice Quality Reporting Program; HOPE is the assessment instrument CMS is implementing to succeed the Hospice Item Set.
Why this section is on the CHPN
Domain 5: Practice Issues is 28 of 135 scored items (20.7%) on the Hospice and Palliative Credentialing Center (HPCC) CHPN examination. HPCC reports results as a scaled score; the passing standard is a scaled score of 500, not a raw percentage and not a 75 cutoff. Many of those Domain 5 items are Medicare regulatory items: if the nurse cannot map a vignette to 42 CFR Part 418, the item is lost.
The Medicare Hospice Benefit is a Part A benefit for beneficiaries who are terminally ill and who elect hospice. Election is not a handshake and not a verbal “we’re on hospice now.” It is a documented legal act that changes what Medicare will pay. The Conditions of Participation (CoPs) are the federal rules a hospice must meet to participate in Medicare. Professional standards (NHPCO, HPNA, NCP) and accreditation manuals matter — they are the next sections — but they do not replace CoPs.
42 CFR Part 418: the CoP map CHPN expects
Part 418 is organized so surveyors and nurses can find the same clocks:
| Subpart | What it governs | CHPN-heavy sections |
|---|---|---|
| B | Eligibility, election, duration | §§ 418.20–418.30 (eligibility, benefit periods, certification, election, discharge, revocation) |
| C | Patient-care CoPs | §§ 418.52–418.78 (rights, assessment, IDG/plan of care, QAPI, infection control, core services) |
| D | Organizational CoPs | Includes § 418.102 Medical director |
A CHPN is not expected to recite every tag number. The exam is expected to test whether the nurse knows which clocks, which signatures, and which services the hospice still owns when census is high and staffing is thin.
Election statement: the benefit does not start on good intentions
Under § 418.24, an eligible individual — or a representative if the individual is incapacitated — files an election statement with a particular hospice. Required content includes:
- Identification of that hospice and of the attending physician, with acknowledgement that the attending physician was the patient’s choice
- Acknowledgement that the person understands the palliative rather than curative nature of hospice for the terminal illness and related conditions
- Acknowledgement that certain Medicare services are waived by the election (care related to the terminal illness and related conditions, except as the regulation carves out)
- The effective date, which may be the first day of hospice care or later, but cannot be earlier than the date of the election statement
- The signature of the individual or representative
For elections on or after October 1, 2020, the statement also addresses hospice coverage responsibility (unrelated services are exceptional and unusual; the hospice should be providing virtually all needed care), cost-sharing information, the right to an election statement addendum when the hospice has determined items, services, or drugs are unrelated, and Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) immediate-advocacy information.
The hospice must file a Notice of Election (NOE) with its Medicare contractor within 5 calendar days after the effective date. Late NOEs make the uncovered days a provider liability — the hospice cannot bill the beneficiary for those days.
Exam trap: Starting visits before a complete election, backdating the effective date, or treating “the family said they want hospice” as an election will fail both a survey and a CHPN item.
Certification of terminal illness (CTI)
§ 418.22 requires a written certification of terminal illness for each benefit period, even when one election continues. The certification must specify that life expectancy is 6 months or less if the illness runs its normal course. Clinical information supporting that prognosis must be in the record. The physician’s brief narrative must reflect this patient’s circumstances — not checkbox boilerplate used for every admission — and must sit immediately before the physician’s signature (or be a signed addendum).
Initial 90-day period: written certification from (1) the hospice medical director, physician designee, or physician member of the IDG, and (2) the attending physician, if the patient has one. Subsequent periods: only the hospice physician listed in (1). If written certification cannot be obtained within 2 calendar days after a period begins, the hospice must obtain oral certification within those 2 days and the written certification before it submits a claim. Certifications may be completed no more than 15 calendar days before election or before the next benefit period.
Core services the hospice cannot give away
§ 418.64 is a high-yield CHPN CoP. A hospice must routinely provide substantially all core services directly by hospice employees. Those services include nursing, medical social services, and counseling. Physician services may be contracted, but contracted physicians still function under the medical director. Counseling must include bereavement (organized program; available up to 1 year after death), dietary when on the plan of care, and spiritual counseling with assessment and reasonable efforts to involve the patient’s own clergy.
The hospice may use contracted staff only to supplement employees under extraordinary or other non-routine circumstances (unanticipated high census, short-term illness absences, temporary travel outside the service area) or under a written arrangement with another Medicare-certified hospice. Highly specialized nursing that is so infrequent that employing it would be impracticable may be contracted. None of that lets a hospice outsource its identity as the provider. Under § 418.100, when services are furnished under arrangement, the hospice retains administrative and financial management and oversight. Arranged services must be authorized by the hospice, furnished safely by qualified personnel, and delivered according to the plan of care.
Interdisciplinary group, plan of care, and assessment clocks
§ 418.56 requires an interdisciplinary group (IDG) that, as a whole, supervises care. The IDG must include, at minimum:
- A doctor of medicine or osteopathy (employee or under contract)
- A registered nurse
- A social worker, marriage and family therapist, or mental health counselor (the 2023 CoP update)
- A pastoral or other counselor
The hospice must designate an IDG registered nurse to coordinate care, keep assessment continuous, and implement the interdisciplinary plan of care. The plan of care is individualized, written, and established by the IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver. It must include pain and symptom interventions, scope and frequency of services, measurable outcomes, drugs and treatments, medical supplies, and documentation of the patient’s or representative’s understanding and agreement. The IDG reviews the plan as often as the condition requires, but no less frequently than every 15 calendar days.
§ 418.54 clocks CHPN loves:
- Initial assessment: hospice RN, within 48 hours after election (sooner if the physician, patient, or representative requests)
- Comprehensive assessment: IDG, in consultation with the attending physician if any, no later than 5 calendar days after election
- Update: at least every 15 days and when the condition requires
Hospice medical director and HQRP / HOPE
§ 418.102 requires the hospice to designate a medical director who is a doctor of medicine or osteopathy, employed or under contract. When the medical director is unavailable, a physician designee assumes the same obligations. The medical director (or designee or physician member of the IDG) reviews clinical information and provides the written certification, considering the primary terminal condition, related diagnoses, current findings, current medications and treatments, and management of conditions unrelated to the terminal illness. The medical director is responsible for the medical component of the hospice’s patient-care program.
Medicare-certified hospices also participate in the Hospice Quality Reporting Program (HQRP). CMS hospice quality reporting continues. HOPE (Hospice Outcomes and Patient Evaluation) is the assessment instrument CMS is implementing to succeed the Hospice Item Set (HIS). CHPN items will not ask you to recite a vendor file spec. They will expect the nurse to treat standardized quality assessment as part of the comprehensive assessment and QAPI workflow, not as optional paperwork after the visit.
CoP-to-nursing implication table
| CoP | Federal requirement | What the CHPN actually does |
|---|---|---|
| § 418.24 Election | Signed election identifying hospice and attending; palliative acknowledgement; waiver of related Medicare services; timely NOE | Do not start the Medicare benefit without a complete election; teach what is waived; watch the 5-day NOE clock |
| § 418.22 CTI | 6-month prognosis; written certification each period; patient-specific narrative | Document decline that supports the prognosis; flag missing signatures, dates, and canned narratives |
| § 418.64 Core services | Nursing, medical social work, physician services, and counseling remain the hospice’s responsibility | Do not treat a staffing contract as a way to offload core care; escalate chronic understaffing |
| § 418.56 IDG / plan of care | Required IDG membership; RN coordinator; plan of care at least every 15 days | Bring current assessment to IDG; make sure the plan matches today’s pain, psychosocial, and spiritual needs |
| § 418.54 Assessment | RN initial ≤48 hours; comprehensive ≤5 days; update ≥ every 15 days | Calendar the clocks; late assessments are survey and payment problems |
| § 418.102 Medical director | MD/DO employee or contract; certifies and recertifies | Route clinical narratives to the medical director; face-to-face findings must reach the certifying physician |
| HQRP / HOPE | Quality reporting continues; HOPE succeeds HIS as the CMS assessment instrument | Complete required assessment items accurately; quality data is a nursing workflow |
A Medicare-certified hospice routinely contracts all nursing visits to a staffing agency because census is high every month. Which statement is most accurate under 42 CFR 418.64?
Which professionals must be included on the hospice interdisciplinary group under 42 CFR 418.56?
A hospice registered nurse is coordinating a new Medicare election. Which action matches the Conditions of Participation?