Wide Support for Opposition to CMS’ Part D Payment Policy for Hospice Patients

The hospice community has been rallying numerous organizations, as well as U.S. Senators and Representatives, to support its request to stop CMS from implementing a policy issued on March 10, 2014, that would change the payment requirements for drugs for hospice beneficiaries . CMS established the policy to prevent duplicate payments for drugs covered under the hospice benefit or waived through the beneficiary’s hospice election. The hospice community’s efforts led to a stakeholder meeting with CMS on June 25, 2014, according to a National Hospice and Palliative Care Organization (NHPCO) press release. More than 30 organizations participated in the meeting.

NHPCO reported that Congressional sign-on letters have been circulated by Senators John D. Rockefeller (W. Va.) and Pat Roberts (Kansas) and Representatives Tom Reed (NY) and Mike Thompson (Calif.) to bring additional focus to the issue. A significant number of Senators and Representatives, identified on the Hospice Action Network website have signed the letters.

The Concerns

NHPCO acknowledged the importance of a policy that would help the government avoid duplication payments for medications of beneficiaries under hospice care. According to NHPCO, however, “participants from the hospice and beneficiary communities as well as the pharmacies and Part D plans were in complete agreement that the implementation of the new policy is unnecessarily depriving patients of their necessary medications and must be halted.” J. Donald Schumacher, NHPCO president and chief executive officer noted “Clearly, the system that recently went into effect wasn’t ready for prime time, and something drastic has to be done to protect dying patients who need their medications in a timely fashion.” Schumacher was hopeful that CMS would acknowledge the urgency of the situation and act quickly to halt it.

The Center for Medicare Advocacy (Center) recognizes that Part D plans might inappropriately pay for medications after a beneficiary elects hospice. For example, if a family member brings a 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 medication.The Center states, however, though the policy laid out by CMS “may prevent insurance companies from bearing the cost of a hospice benefit, “CMS’ solution to the problem inappropriately burdens the dying and their families.” The Center believes that the insurance companies that administer Medicare Part D plans can easily design a system to retroactively review medications covered for hospice patients and seek reimbursement from hospice providers, when necessary.

The Policy

Under Medicare law, hospice is responsible for covering all drugs or biologicals for the palliation and management of terminal and related conditions. Drugs and biologicals are covered under the Part A per-diem payment to a hospice program and, therefore, are excluded from coverage under Part D. Some drugs covered prior to the hospice election will continue to be part of the hospice plan of care, such as for the treatment of diabetes and hypertension that are unrelated to the terminal illness. Under the policy, CMS established prior authorization requirements on all drugs for beneficiaries who have elected hospice to determine whether those drugs are coverable under Part D.

When the hospice patient or her family tries to fill a prescription at a pharmacy, the pharmacy will get a message stating “Hospice Provider-Request Prior Authorization for Part D Drug Unrelated to the Terminal Illness or RelatedConditions.” The pharmacy must contact the beneficiary or prescriber to determine whether the medication is related to the terminal illness and, if so, bill the hospice for the cost of the medication. If the medication is not related to the terminal illness, however, the pharmacy cannot fill the prescription. Instead, the pharmacy will provide the standardized pharmacy notice with appeal rights. If the insurance company is satisfied that the prescription is not related to the terminal illness, the insurance company can tell the pharmacist to override the denial. The policy became effective May 1, 2014.