You sign about forty pages the day a parent goes on hospice. You sign them in a hallway, or on a rolling tray table, or across a kitchen counter while somebody's dog barks in the other room. You are not reading them. Nobody reads them. You're watching your mother's face, trying to work out whether she understood what the nurse just said, and the pen keeps moving.
Buried in that stack is a single page that decides who pays for her oxygen.
Most families never see it. Under the rules in place since 2020, the hospice only had to give you that page if you asked for it, by name, and almost nobody knows to ask. Commenters told CMS that only about one in five patients ever requested it, and some reported that as few as 5 to 7 percent of admissions ended up with a completed one on file.
That changes October 1.
I spent eight years buying houses from families who were a few weeks past a hospice admission and drowning in bills nobody had warned them about, and then I walked away from that side of the table. Here's what that vantage point taught me, and it's the reason this small rule change is worth twenty minutes of your evening: the money that wrecks a family at the end is almost never the big obvious number. It's the small stuff that everyone assumed was covered, quietly wasn't, and shows up as a $1,400 statement six weeks after the funeral.
So let's look at the page. What's on it, what it actually means, and the four things to do with it before you sign.
What CMS Finalized on August 3
On August 3, 2026, the Centers for Medicare and Medicaid Services published its FY 2027 hospice final rule in the Federal Register. Most of it is rate-setting. CMS finalized a 2.3 percent hospice payment update for fiscal year 2027, set the hospice aggregate cap at $36,174.75 (up from $35,361.44), and estimated the whole rule sends about $755 million more to hospices next year.
The part that lands on your kitchen table is much smaller and much more useful.
CMS finalized a requirement that every hospice give every Medicare patient a written document titled "Patient Notification of Hospice Non-Covered Items, Services, and Drugs." It applies to hospice elections beginning on or after October 1, 2026. You don't have to request it anymore. The hospice has to furnish it within the first 5 days of the effective date of the election, and if the plan of care changes in a way that changes those determinations, the hospice has 3 days to get you an updated version in writing.
Why CMS bothered comes down to the numbers, and CMS put them in the rule. Medicare payments for non-hospice Part A and Part B items and services received by people who were already enrolled in hospice climbed from nearly $790 million in FY 2020 to over $2 billion in FY 2024. That's an increase of nearly $1.3 billion, or 160 percent. Add Part D drugs and the FY 2024 total runs over $2.8 billion.
Then there's the line that should stop you cold. CMS wrote that in FY 2024, beneficiary cost sharing for people who had elected hospice came to $510 million for Parts A and B. That's families paying deductibles and coinsurance out of pocket on a benefit that's supposed to cost them almost nothing.
CMS also said it is "particularly concerned" that items foundational to hospice care are being billed outside the hospice benefit, and it listed them by name: wheelchairs, hospital beds, oxygen supplies, wound care supplies, incontinence supplies, catheters, needles, and common palliative drugs. CMS even noted it had received reports from families asking whether there's a limit on basic supplies like adult diapers, because some hospices weren't providing them or were rationing them.
What Hospice Is Supposed to Cover, Which Is Nearly Everything
Here's the part most families get backwards, and getting it backwards costs money.
When your mother elects hospice, she waives her right to Medicare payment for treatment of her terminal illness and related conditions, except through the hospice she chose and her attending physician. In exchange, that hospice becomes responsible for essentially all the care she needs for that illness. CMS has held since 1983 that the waiver requires hospices to provide virtually all the care a terminally ill patient needs. Not some of it. Virtually all of it.
Per Medicare.gov, you pay nothing for covered hospice services from a Medicare-approved hospice. The only routine cost sharing is up to $5 per prescription for outpatient drugs for pain and symptom management, and 5 percent of the Medicare-approved amount for inpatient respite care, which can't exceed the inpatient deductible.
So when a family gets a bill for a hospital bed, or for wound supplies, or for a nebulizer, the question isn't "how do we pay this." The question is "why isn't the hospice covering this." The addendum is the document that forces the hospice to answer that question in writing, in advance, in plain language, and to point to the guideline it relied on.
Two benefits nobody tells you about are worth naming here, because they're the ones exhausted families most need. Under federal regulation, nursing care can be covered on a continuous basis for as much as 24 hours a day during a period of crisis, to keep your mother at home. And inpatient respite care exists purely to relieve the family, though the same regulation limits it to no more than five consecutive days at a time. If you're the one sleeping in the recliner, those two exist for you, and you have to ask.
The Room Is the Gap, and That's Where the House Comes In
Now the hard part. Medicare.gov is blunt about it: Medicare doesn't cover room and board. Not at home, not in a nursing home, not in an assisted living community, not in a hospice inpatient facility. If your father lives in a facility and elects hospice, you may still owe the facility for the room.
Read that again, because it's the whole shape of the problem. Hospice covers the nurse, the aide, the medications, the equipment, the social worker, the chaplain, and the bereavement counseling. It does not cover the roof. And the roof is usually $5,000 to $8,000 a month.
That's the moment a lot of families start looking at the house. Not because anyone planned it that way, but because the room bill lands and the only asset that can cover it is sitting empty across town.
Here's where I'd ask you to slow down. Calling a real estate agent starts a clock. That's not the agent being pushy, that's the job description. An agent's whole professional instinct is to get the house on the market by the weekend, and that instinct is completely correct for somebody who's ready. If you are three weeks into a hospice admission, you are not ready. You're being asked to make a permanent decision about your family's largest asset during the worst month of your life.
What you actually need first is a number, not a listing. What does the room cost, what does the empty house cost you every month to hold, and how long does the gap between them run. Sometimes the answer is that you have far more time than the panic suggests. Sometimes it's that a short-term solution buys you six months. And sometimes it really is time to sell, in which case you should sell on purpose, with somebody in your corner, instead of selling because the phone rang.
Not All Hospices Bill the Same Way
One more finding from the rule, because it's the kind of thing you can act on.
CMS reported that in FY 2024, people receiving hospice care from for-profit hospices had, on average, nearly 167 percent higher non-hospice spending per day than people under non-profit hospice care. In FY 2022 that gap was 60 percent. It nearly tripled in two years.
Non-hospice spending is the stuff getting billed outside the benefit. Higher non-hospice spending per day means more items being called "unrelated" and pushed back onto Medicare Part A, Part B, Part D, and onto your family's deductible. CMS didn't accuse anyone of anything, and plenty of for-profit hospices do excellent work. But it's a real pattern in the government's own claims data, and it tells you which question to ask on the first visit.
The Office of Inspector General has been flagging this for years. CMS cited three OIG audits in the rule, including one finding Medicare paid $6.6 billion to non-hospice providers over ten years for items and services furnished to hospice patients, and another finding an estimated $117 million over four years for durable medical equipment.
Four Things to Do With That Page
1. Ask for the addendum on day one, even before October 1
If the election happens before October 1, 2026, the old rule still applies and you have to request it. So request it. Per Medicare.gov, the hospice has to give you the list within 3 to 5 days depending on when you asked. For elections on or after October 1, it comes automatically within 5 days, but asking on day one still gets the conversation started sooner.
2. Read the "unrelated" list line by line, and push back on anything foundational
The addendum has to list every condition, item, service, and drug the hospice has decided is unrelated to the terminal illness, plus a written clinical explanation in language you can understand and a reference to the guideline behind it. If you see a hospital bed, oxygen, wound supplies, incontinence supplies, a catheter, or a common comfort medication on that list, ask why. Those are the exact categories CMS named as concerning.
3. Sign it, but know exactly what your signature means
Federal regulation is explicit here: signing the addendum is acknowledgment that you received it, not agreement with the hospice's determinations. If you refuse to sign, the hospice has to document why on the form itself. So sign, keep your copy, and treat it as evidence rather than as consent.
4. Use immediate advocacy if you disagree
The addendum must tell you about your right to immediate advocacy through the Beneficiary and Family Centered Care Quality Improvement Organization if you disagree with what the hospice decided. That's a free, fast process and it exists specifically for this. You can find your BFCC-QIO through CMS or by calling 1-800-MEDICARE. Also, per Medicare.gov, you have the right to change your hospice provider once during each benefit period.
One last practical note that saves real money: per Medicare.gov, contact the hospice team before any emergency room visit, hospital admission, or ambulance trip. If the hospice didn't arrange it and it's related to the terminal illness, you might have to pay the entire cost.
Frequently Asked Questions
What is the hospice election statement addendum?
It's a written document titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs. It lists every condition, item, service, and drug the hospice has determined is unrelated to the terminal illness and therefore won't be covered by the hospice, along with a clinical explanation in plain language and references to the guidelines behind that decision. Starting with hospice elections on or after October 1, 2026, CMS requires hospices to provide it to every Medicare patient automatically.
Do I have to ask for the hospice non-covered items list?
Not after October 1, 2026. In a final rule published August 3, 2026, CMS made the addendum mandatory for all hospice elections beginning on or after that date, and the hospice must furnish it within the first 5 days of the effective date of the election. For elections before October 1, the older rule applies and you have to request it, in which case Medicare.gov says the hospice must provide it within 3 to 5 days depending on when you asked.
Does Medicare hospice pay for room and board in assisted living or a nursing home?
No. Medicare.gov states plainly that Medicare doesn't cover room and board, whether hospice care happens at home, in a nursing home, or in a hospice inpatient facility. Hospice covers the nursing, aide visits, medications, equipment, counseling, and bereavement support related to the terminal illness, but the housing bill stays with the family. The one exception is short-term inpatient or respite care that the hospice team arranges, where Medicare covers the facility stay.
What does hospice cost a family out of pocket?
Per Medicare.gov, you pay nothing for covered hospice services from a Medicare-approved hospice. The routine cost sharing is limited to a copayment of up to $5 for each prescription for outpatient pain and symptom management drugs, and 5 percent of the Medicare-approved amount for inpatient respite care, which cannot exceed the inpatient deductible. Anything the hospice classifies as unrelated to the terminal illness goes back to regular Medicare, where your parent owes the usual deductibles and coinsurance.
What can I do if the hospice says something isn't covered and I disagree?
The addendum itself has to tell you about your right to immediate advocacy through the Beneficiary and Family Centered Care Quality Improvement Organization, which is a free and fast dispute process run through CMS. Start there, and call 1-800-MEDICARE if you need help finding the right one for your state. Signing the addendum does not waive that right, because federal regulation says a signature only acknowledges receipt. You also have the right to change your hospice provider once during each benefit period.
About Ryan Riggins
Ryan Riggins is a senior transition advisor and former house flipper. After 8+ years buying homes from families in transition, he walked away from the cash-buyer side to help families avoid the $50K mistakes he used to profit from. Based in Greensboro, NC. NC Real Estate License #361546, eXp Realty. Founder of Riggins Strategic Solutions and the SeniorSafe app.
Want to see the holes before they cost you? The free Medicare Gap Analyzer walks through what Medicare doesn't cover in about three minutes: rigginsstrategicsolutions.com/tools/medicare-gap-analyzer
Want a step-by-step guide? The free Simple Blueprint walks through every stage of a senior transition: rigginsstrategicsolutions.com/freeguide
Ready for the full system? The Senior Transition Blueprint is free, all 20 modules and 69 tools: rigginsstrategicsolutions.com/the-blueprint
Need a personalized plan? The Senior Transition Roadmap is free, by application. It adds calls with Ryan and 90 days of email support: rigginsstrategicsolutions.com/the-roadmap
Selling a parent's home? Ryan finds and vets the right local agent for your situation and stays in your corner on the whole sale, at no added cost to your family: rigginsstrategicsolutions.com/in-your-corner
Coordinate the family in one place. SeniorSafeApp keeps daily check-ins, medications, and documents where the whole family can see them: seniorsafeapp.com
Sources
All sources checked August 7, 2026.
Federal Register, "Medicare Program; FY 2027 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements," CMS-1851-F, document 2026-15686, published August 3, 2026, effective October 1, 2026. The 2.3 percent payment update, the $36,174.75 cap versus $35,361.44 for FY 2026, the $755 million economic impact, the mandatory addendum finalized as proposed, the non-hospice spending figures, the $510 million in FY 2024 beneficiary cost sharing, the for-profit comparison, the flagged item list, the adult diaper reports, the commenter statements on how rarely the addendum was requested, and the cited OIG audits A-09-20-03015, A-09-23-03024, and A-09-20-03026.
Code of Federal Regulations, 42 CFR 418.24, as amended by that rule. The addendum title and contents, the clinical explanation requirement, the BFCC-QIO advocacy right, the signature language, the 5 day furnishing window, and the 3 day update window.
Code of Federal Regulations, 42 CFR 418.204. Continuous nursing care up to 24 hours a day during a period of crisis, and respite limited to five consecutive days at a time.
Medicare.gov, "Hospice care." Zero cost for covered services, the $5 prescription copayment, the 5 percent respite coinsurance, the room and board exclusion, the current 3 to 5 day request timeframe, the warning about emergency and inpatient services, the 6 month certification, the benefit periods, and the right to change providers once per period.
CMS, "Beneficiary and Family Centered Care Quality Improvement Organizations" (cms.gov). How to reach the BFCC-QIO serving your state.
Education, not advice. Hospice payment rates and the aggregate cap reset every October 1, Medicare cost-sharing amounts reset every January, and what a specific hospice covers is a clinical determination made patient by patient. Confirm current details with the hospice, with 1-800-MEDICARE, or with your free local State Health Insurance Assistance Program.
