Hospice Drug Rule Revised by CMS

Members | July 20, 2014

On July 18, the Center for Medicare and Medicaid Services (CMS) released Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice, a notice that encourages sponsors to place beneficiary-level prior-authorization requirements on only 4 categories of prescription drugs identified in a June 2012 Office of Inspector General (OIG) Report. This change in policy will significantly reduce the the challenges and difficulties present under the current full Prior Approval policy.

On July 18, the Center for Medicare and Medicaid Services (CMS) released Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice, a notice that encourages sponsors to place beneficiary-level prior-authorization requirements on only 4 categories of prescription drugs identified in a June 2012 Office of Inspector General (OIG) Report

 

  1. Analgesics.
  2. Anti-nauseants (antiemetics).
  3. Laxatives.
  4. Anti-anxiety drugs (anxiolytics) 

According to CMS and the OIG, these drugs are “nearly always” considered hospice-related.

 

Medicare Part D prescription drug plans will continue to pay for drugs for diabetes, heart disease or other chronic conditions still used by hospice patients, but not directly related to their terminal illness. 

Unlike medications covered by hospice, the beneficiary may have a copay for drugs unrelated to the terminal illness and/or related conditions.

Under this revised guidance, hospice providers are encouraged to report a beneficiary’s Medicare hospice election to the Part D sponsor and identify any drugs in the 4 categories determined to be eligible for coverage under Part D because the drugs are unrelated to the terminal illness and/or related conditions prior to the submission of a claim. 

This communication, however, is not a coverage determination or prior authorization request. Rather, the information provided by the hospice can be used by the Part D sponsor to override the beneficiary-level hospice prior authorization at point-of-sale (POS).

If a claim has been rejected by a Part D sponsor due to the beneficiary-level hospice prior approval, the pharmacy or beneficiary may contact the hospice provider for a statement that the drug is unrelated to the terminal illness and related conditions.

The hospice provider should contact the Part D sponsor to provide an oral or written statement or provide a written statement to the pharmacy or the beneficiary to transmit to the Part D sponsor. The sponsor should accept this information to override the point- of service reject without requiring that the beneficiary, or others on their behalf, request a coverage determination. 

When either the beneficiary, the beneficiary’s appointed representative, or the prescriber requests a coverage determination, the sponsor should contact either the prescriber or the hospice provider and accept and use the statement that the drug is unrelated to the terminal illness and/or related conditions provided by either the prescriber or hospice. 

A hospice provider cannot request a coverage determination on behalf of the beneficiary. CMS has authorized the use of a 2-page form to replace the list of data elements as the hospice prior approval drug form to further facilitate this process.

In those scenarios in which the drug is determined to be a hospice liability, the sponsors and hospices should negotiate repayment.

LeadingAge is pleased that CMS addressed these issues. The reduced number of medications subject to prior approval will significantly reduce the the challenges and difficulties present under the full Prior Approval policy.