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National Association for Home Care & Hospice
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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Advocacy Center Decries Drug PA for Hospice Patients

NAHC/HAA seek Reports of Part D Plan Issues
April 29, 2014 10:51 AM

In a recent online alert- reprinted in its entirety below - the Center for Medicare Advocacy(CMA) challenges as “illogical” and “immoral” the Centers for Medicare & Medicaid Services’ (CMS) decision to mandate prior authorization under Part D for drugs prescribed for hospice patients. CMA equates the policies contained in the March 10 guidance, which takes effect May 1, to “burden shifting to the dying patient” under which the patient’s drug submission must first be rejected by the drug plan and the patient must actively pursue a coverage determination from the plan in order to secure coverage. CMA is a national nonprofit, nonpartisan organization that provides education, advocacy and legal assistance to help older people and people with disabilities obtain fair access to Medicare and necessary health care.

The National Association for Home Care & Hospice (NAHC) and its affiliated Hospice Association of America (HAA) is working with CMA and other stakeholders to address the considerable problems associated with CMS’ Part D/ prior authorization policies.

The issue of Part D drugs and hospice patients has been covered extensively in previous NAHC publications. NAHC continues to receive reports of Part D plans refusing to work with hospice providers to establish appropriate responsibility for drug coverage.  With the May 1 deadline fast approaching, NAHC is continuing to monitor emerging issues related to Part D drug coverage for hospice patients, and is requesting that providers submit information regarding their experiences with Part D plans that may be affecting the timeliness with which beneficiaries are able to access needed prescription medications.  These examples will be used in advocacy efforts related to Part D and hospice patients. 

Please send examples containing the following informational elements to

Date of incident:

Patient hospice diagnoses:

Unrelated drug that should be covered under Part D/condition:

Brief description of the Part D Plan response/reaction:

Impact of Plan response:

Name of Part D Plan:

The Center for Medicare Advocacy’s Alert regarding Part D and hospice is printed in its entirety below:

Hospice and Access to Medications – New CMS Guidance

On March 10, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance" (Guidance).   The Guidance identifies a billing problem related to medications after Medicare beneficiaries elect hospice, and designs a solution effective May 1, 2014.   The Guidance also describes the solution's "implications for beneficiaries."  ThisAlert will discuss the problem and solution.  A second Alert will discuss the identified implications for beneficiaries. 


Medications that should be covered by the Medicare Hospice Benefit are sometimes paid for by the insurance companies that administer Medicare Part D plans.  To prevent this from happening, effective May 1, 2014, all prescribed medications for hospice patients billed to Medicare Part D will initially be denied coverage.  To get their medications, hospice patients will have to initiate and ultimately succeed at a Medicare appeal.  In other words, to protect insurance companies, dying patients will have to jump through hoops to get medically necessary, potentially life-sustaining medications. 


Hospice is care for the dying.  It is palliative care, which means it is patient and family-centered, and optimizes quality of life by anticipating, preventing, and treating suffering.  Good hospice care addresses physical, intellectual, emotional, social and spiritual needs, and facilitates autonomy. 

Since 1983 Medicare has paid for hospice care when beneficiaries are certified as having a life expectancy of 6 months or less.  Medicare providers are paid a per diem that is designed to cover all services necessary for the palliation and management of the terminal illness and related conditions.  Hospice coverage includes the cost of medications related to the terminal illness.  When Medicare beneficiaries elect the hospice benefit, they forego Medicare coverage for curative treatment related to their terminal illness, but are still eligible for Medicare coverage for all other covered care.  For instance, if a Medicare beneficiary with liver cancer elects the hospice benefit, Medicare will no longer pay for treatment to cure the cancer, but it will continue to pay for care related to other illnesses like diabetes and hypertension. 

Medicare Part D

In 2006, Medicare began paying for prescription medications.  Rather than simply doing this through traditional Medicare, Congress added a new "part" to Medicare – Medicare Part D.  In an unnecessarily complex system, the prescription drug benefit is offered by an array of insurance companies, each offering one or multiple plans with a dizzying amount of formularies for beneficiaries to choose from.  Each year, Medicare beneficiaries are expected to review their medication needs and to choose the plan that offers the best formulary and the best price. 


The CMS Guidance indicates that Part D Plans might inappropriately pay for Hospice medications.  This is a real possibility, but CMS's solution to the problem inappropriately burdens the dying and their families. 

When the Prescription drug benefit was added to Medicare, very little thought was given to how it would interface with the hospice benefit.  Guidance issued at the time appropriately indicated that hospice providers should pay for palliative medications related to the terminal illness and that the insurance companies that offered the Part D plans should pay for all other medications.  However, no process was created to inform the insurance companies when Medicare beneficiaries elected hospice. 

The CMS Guidance raises the possibility that, after Medicare beneficiaries elect hospice, the insurance companies may continue to pay for medications that should properly be covered by the hospice benefit.   For instance, prior to electing hospice, a beneficiary may need and receive medications for pain and nausea related to cancer.   These medications would be covered by her Part D plan.  If the beneficiary elects the Hospice Benefit because of the cancer, the hospice provider becomes responsible for covering the pain and nausea medications.  However, if a family member brings the prescription to a local pharmacy, the pharmacy will bill the insurance company administering the beneficiary's Part D plan.  Because the insurance company does not know the beneficiary elected hospice, it will probably pay for the prescription medications. 

To solve this problem, CMS designed a process whereby Part D plans can find out via the Medicare Beneficiary Database when a beneficiary elects hospice.  CMS then advises them that, "drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances."  The Guidance then directs the insurance companies to "place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are coverable under Part D." (emphasis in original)

The new Guidance means that whenever the hospice patient or her family tries to fill a prescription at the pharmacy, the pharmacy will get a message stating, "Hospice Provider-Request Prior Authorization for Part D Drug Unrelated to the Terminal Illness or Related Conditions."  Then it will be the duty of the pharmacy to contact the beneficiary or prescriber to determine whether the medication is related to the terminal illness.  If the medication is related to the terminal illness, the pharmacy will bill the hospice for the cost of the medication.  If the medication is not related to the terminal illness, the pharmacy cannot fill the prescription.  Instead, the pharmacy will provide the standardized pharmacy notice with appeal rights (i.e., Prescription Drug Coverage and Your Rights – Form CMS- 10147).

So, even when it is determined that the medication is not related to the terminal illness, to get her medications the beneficiary or "appointed representative" will have to contact the insurance company and request an appeal.  If this is done, the insurance company will contact the prescriber and ask him or her to complete the prior authorization form and submit it by fax or mail.  CMS imagines that if the prescriber is unwilling to complete the prior authorization paperwork, the insurance company will call the hospice and ask it to explain whether the medication is related to the terminal illness. 

If the insurance company is satisfied that the medication is not related to the terminal illness, CMS expects the Part D plan to contact the pharmacy and instruct the pharmacist regarding how to override the denial.  CMS indicates that the decision should be made within 72 hours, but that the adjudication timeframe may be extended "pending receipt of the necessary information" or "based on the facts and circumstances of the case."

This process may prevent insurance companies from bearing the cost of hospice medications, but it does this by burdening the hospice patient and his family.  For instance:

Mr. B. was 83 years old.  He was quite healthy and independent, living an active life with the help of a few medications, including one to control his blood pressure.  After experiencing some uncomfortable indigestion, he went to his physician.  Sadly, he was diagnosed with metastatic pancreatic cancer and given a limited life expectancy.  He elected the hospice benefit.  Under this new protocol, when his wife goes to the pharmacy to re-fill his life sustaining blood pressure medication to prevent a stroke, the request for payment will be automatically denied.  This is despite the fact that Mr. B. will be at high risk for a stroke without the medication.  Mrs. B. will have to contact the insurance company to appeal the denial.  The insurance company may not speak to Mrs. B. because she is not an "appointed representative."  Mr. B. may not feel well enough to call or to complete the required paperwork.  If Mr. B is up to negotiating the appeal process, the insurance company should then call Mr. B.'s doctor who may or may not agree to fill out the pre-authorization form.  If Mr. B's doctor does not fill out the form, the insurance company may or may not contact the hospice provider.  In the meantime, due to a protocol designed to save the insurance company money, Mr. B. may have a stroke. 


This burden-shifting to the dying patient is illogical and immoral. 

CMS has erred in assuming that most hospice patients will not continue to have Part D covered medications.  Most older Americans are on medications for chronic conditions, and some of these medications, like Mr. B's hypertension medication, are very important as they prevent premature death or devastating injury.  Further, CMS has erred in designing a system further burdening the dying and their families.  The insurance companies that administer Medicare Part D plans can easily design a system to retroactively review medications covered for hospice patients.  If appropriate, the Part D plans can seek reimbursement from hospice providers.  Such a process is already imagined in the Guidance for situations when insurance companies pay for hospice medications before determining the beneficiary has elected hospice. 

Insurance companies, though not legally responsible, should continue to bear the risk of initially paying for medications for hospice patients.  In weighing the financial concerns of insurance companies against the legal rights of dying Medicare beneficiaries, clearly the rights of hospice patients and their families should prevail.





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