Home Health & Hospice Week

Hospices are already seeing preauthorization denials, they report.

Some tweaks in Medicare’s new policy memo outlining Part D drug coverage for hospice patients may be an improvement over CMS’s first draft, but hospices still will face preauthorization for patients’ drugs starting May 1 — if they don’t already.

Change: In a Dec. 6 memo on Part D coverage of drugs for hospice patients, the Centers for Medicare & Medicaid Services said “hospices are required to provide virtually all the care that is needed by terminally ill individuals” who elect the hospice benefit — including drugs (see Eli’s HCW, Vol. XXII, No. 43). The new memo simply says “the hospice is responsible for covering all drugs or biologicals for the palliation and management of the terminal and related conditions.”

Another change: The new memo also does not include the original memo’s statement that “we expect drugs covered under Part D for hospice beneficiaries will be extremely rare.” Instead, it says “we expect drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances.”

Despite the softer language, CMS still directs Part D plans to “place beneficiary-level prior auth-orization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are coverable under Part D.” The original deadline for the PA requirements was March 1, but CMS has pushed it back to May 1.

Hospices that tuned into CMS’s March 5 Open Door Forum hoping for more information about the policy were disappointed, since CMS pushed back its release date of the memo until after the forum, and therefore didn’t discuss it.

However, one participant asked CMS why her hospice was already getting denials for drugs from a Part D sponsor when the memo had not taken effect yet.

CMS issued a call letter in April 2013 “in which we strongly encouraged [Part D plans] to establish prior authorization requirements … on drugs for beneficiaries who had elected hospice,” a CMS rep said. “It wasn’t a requirement, so not all of them would be doing it. But there are some sponsors who have implemented those effective Jan. 1.

Warning: Don’t be surprised when you start receiving claims rejections for every drug claim to a Part D plan — that’s part of the new PA process, notes the National Association for Home Care & Hospice. “Please note that these are rejections and not denials,” the trade group says.

Your beneficiary or his prescriber will have to contact the Part D plan to request coverage of the drug, NAHC explains. 

Note: The newest memo is at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/Part-D-Payment-Hospice-Final-2014-Guidance.pdf. For tips on complying with hospice drug coverage requirements, see Eli’s HCW, Vol. XXII, No. 43.