Part D Prior Authorization Form - Medicare Beneficiaries Enrolled In Hospice
October 8, 2014 09:50 AM
CMS is asking for comments on a proposed Part D prior authorization form to be used for Medicare beneficiaries enrolled in hospices. The OIG and CMS have identified concerns that Medicare Part D may be paying for medications that should be provided and covered by hospices. As a result, CMS proposed and implemented a prior authorization process in 2014 and updated that guidance in July of 2014. The updated guidance calls for beneficiary-level prior authorization (PA) requirements on the following four categories of prescription drugs identified by the OIG as typically used to treat the common symptoms generally experienced during the end of life: analgesics, anti-nauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). In order for a drug to be covered under Medicare Part D while a beneficiary is enrolled in the Medicare hospice benefit, the drug must be completely unrelated to the principle hospice diagnosis and/or any related conditions.
The industry in conjunction with the National Council for Prescription Drug Programs, (NCPDP) has developed a standard form that with minor modifications will meet the program needs. CMS will encourage use of this form as soon as it is approved and will likely propose requiring its use in future rulemaking. The standard form provides a vehicle for the hospice provider, prescriber or sponsor to document that the drug prescribed is “unrelated” to the terminal illness and related conditions. It also gives a hospice organization the option to communicate a beneficiary’s change in hospice status and/care plan to Part D sponsors.
The new form will be completed by the prescriber or the beneficiary’s hospice. If the prescriber or hospice provides the information verbally to the Part D sponsor, then the form must be completed by the sponsor. Information provided on the form will be used by the Part D sponsor to establish coverage of the drug under Medicare part D.
Again, this form is being proposed and CMS is seeking comments from hospices and other stakeholders. A draft of the form was included in the July 2014 guidance and its encouraged at that time. This draft form can still be used until the form has officially been approved.
The federal register announcement regarding the proposed form can be found here.
The proposed form - which is essentially the same as what was shared in July 2014 - and the supporting statement can be found here.
Comments on the proposed form are due to CMS by December 2, 2014. NAHC and HHA are compiling comments. Please submit your comments by November 27 to Katie@nahc.org or TMF@nahc.org.