Part D and Hospice Rules Mucking Up Beneficiaries’ Last Days

Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries’ last days. The National Hospice and Palliative Care Organization described the meeting as “an important first step at righting the wrongs being faced by dying Medicare patients.”

Previously, hospice (under Medicare Part A) paid only for the drugs that patients needed for palliation and management of the terminal illness and related conditions, and Medicare Part D covered drugs for hospice patients’ unrelated conditions. Under the new rule, CMS requires a beneficiary level prior authorization process for all hospice and Part D providers to determine responsibility of drug coverage, and hospice must cover medications related only  to the hospice diagnosis.

CMS’ expectations are unrealistic. Putting prior authorizations on everything adversely impacts beneficiary access to drug therapies and causes agonizing delays at the point of service. Consider this: first, it has to be determined if the drug in question is covered under Part A or D. If Part A, then you have to figure out if it’s even covered under the hospice formulary and beneficiary refuses to try formulary equivalent first or drug is not reasonable or necessary  per the hospice provider if not and the beneficiary wants the drug, it will be self-pay. If it’s neither Part A nor D, then the beneficiary must self-pay. If covered under Part D and the prescriber is not hospice affiliated, the sponsor has to jump through hoops, including what to do if the prescriber is unable or unwilling to coordinate with the hospice provider.Then, if the drug has prior authorization on Part D it would have to satisfy those requirements. Plans have to be able to accept and save proactive determinations from hospice. It’s an administrative nightmare. For 2014 only, CMS is universally allowing Plans to treat hospice coverage determinations as exceptions. That in and of itself shows that they are not sure how best to handle this mess.

With end-stage patients (the only kind you get in hospice), it is often difficult to discern which drugs are used for symptom management and what drugs are really for chronic conditions that if in hospice should not be treated, such as diabetes or hypertension meds. The hospice industry has reported widespread confusion and disputes that have made it harder for patients to get their drugs.

Seventy senators signed onto a letter circulated by Sens. Jay Rockefeller (D-WV) and Pat Roberts (R-KS), calling for CMS to suspend the rule. “We ask that CMS immediately suspend the Guidance and begin a process to develop an alternative approach which will ensure both that the right individual or entity pays for the hospice patient’s medications and that the patient get the medication that he or she requires without interruption,” they write.

We agree and hope CMS goes back to the drawing board on this rule. Calm and freedom from pain should define a beneficiary’s last days, not administrative hoops and preauthorizations.




If you’ve just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what’s next. Register now >>

The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Contact us today to learn how we can help >>

John Gorman
John Gorman

Under John's leadership, Gorman Health Group has become the leading professional services and solutions firm for government-sponsored health care, providing thought leadership and expert strategic, operational, and technology-based solutions. Read more

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