Medicare Part D Medications and Hospice
October 24, 2013 10:08 AM
In recent years, the Centers for Medicare & Medicaid Services (CMS) and other agencies have increased oversight of Medicare hospice with particular emphasis on ensuring that goods and services appropriately covered under the benefit are not being charged to other areas of the Medicare program. In July 2012 the Office of the Inspector General (OIG) released a report “Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice.” In particular, the following categories of medications were of concern:
Prescription drugs used to treat COPD and ALS
CMS reported, as part of the FY2014 Final Wage Index and Payment Rule, that its hospice payment reform contractor, Abt Associates, has found additional evidence that “drugs for Medicare hospice beneficiaries are being submitted through Part D prescription programs instead of being covered under the Medicare Hospice Benefit as required by the statute. In 2010, 773,168 Medicare hospice beneficiaries were enrolled in Part D. Of these individuals, almost 15 percent received over 334,000 analgesic prescriptions through Part D during hospice enrollment totaling $13,000,430.... During 2010, Medicare hospice beneficiaries received 5,878,425 prescriptions of all classes totaling $351,750,202. These drug classes encompassed other hospice-related drugs including medications for nausea, shortness of breath, anxiety, constipation, diarrhea, depression, as well as disease-specific medications for the reported principal hospice diagnosis. We continue to conduct ongoing analysis regarding the claims for Medicare hospice beneficiaries to ensure that hospice providers are covering the required services, drugs, supplies, and DME as required by our regulations at 42 CFR 418.200, 418.202, and 418.204.”
In April 2013, CMS released the Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. On pages 135-137 of this document is the 2014 Hospice Drug Policy, which states: “In its 1983 Final Rule, which implemented the hospice benefit, CMS interpreted related conditions broadly, and wrote that hospices are required to cover virtually all the palliative care needed by terminally ill patients (48 FR 56010). Drugs for the palliation and management of the terminal illness and related conditions are the responsibility of the hospice, and as CMS has noted in rulemaking, at the end of life, most conditions are related. Thus, when a sponsor [Part D Plan] receives a transaction reply report (TRR) showing a beneficiary has elected hospice, the sponsor must have controls in place to comply with this requirement.”
The 2012 OIG report was referenced and Part D sponsors were told it is permitted to use approaches, such as pay-and-chase, to resolve payment responsibility for hospice patients, but plans were also strongly urged to establish preauthorization review for certain drugs prescribed for hospice patients to ensure that drugs for the terminal or related conditions are financed by the hospice.
The National Association for Home Care & Hospice (NAHC) and its affiliated Hospice Association of America (HAA) have heard from hospice providers that some Part D sponsors are requiring preauthorization of drugs for hospice patients; the Part D program is also engaged in efforts to recoup payment for drugs (going back to 2011) that were covered under Part D but may have been appropriately charged to the hospice. We have also received reports that CMS contractors for the Medicare Part D program are mailing hospices with requests of information about hospice beneficiary demographics and hospice enrollment data such as dates of service and diagnoses. Hospices are reminded that they are financially responsible for medications prescribed for the palliation and management of the terminal illness and any related condition(s).
NAHC and HAA encourage hospices that may be requested to pay for a medication that does not meet this criteria to share the information, as copied above, from the 2014 Hospice Drug Policy with pharmacy/Part D sponsor. NAHC and HAA are seeking additional information about these activities and will provide updates through NAHC Report, Hospice Notes, and the NAHC member listserv. If your hospice has experienced any activities in this area please let us know at Katie@nahc.org or firstname.lastname@example.org.