Update on CMS Guidiance on Medication Access for Hospice Service

Nancy Leveille in Clinical & Quality

AHCA notified NYSHFA of an update to CMS Guidance on Medication Access for Hospice Service.  The following is a July 23 memo from AHCA highlighting the key issues.

Last week, we shared an overview of the highly problematic May 1 Centers for Medicare and Medicaid Services (CMS) guidance on Part D and hospice drug coverage which caused significant confusion among Part D Prescription Drug Plans (PDPs), hospice providers, pharmacies, consultant pharmacists, and skilled nursing center providers (SNF), resulting in a lag in determination of financial responsibility and potential interference with timely availability of medications.  In an attempt to minimize these situations, AHCA/NCAL provided preliminary strategies to help reduce confusion among responsible parties (see July 17th email from Mike Cheek –  Challenges with Medication Access for Hospice Patients – attached).

On July 18, 2014 CMS released interim guidance intended to address the issues resulting from the May 1 Guidance on Part D and hospice drug coverage (see July 18th Email from Mike Cheek –  CMS Releases Part D & Hospice Medication Access  – attached).  After thorough review of the recent guidance, AHCA/NCAL believes that the strategies previously shared are still pertinent, with the exception that CMS no longer expects the extent of detail provided in the prior authorization (PA). Below please find a detailed explanation of these strategies as they relate to the July 18, 2014 interim CMS guidance.

Strategies to manage policy regarding Part D payment for drugs for hospice beneficiaries
Based on the July 18, 2014 guidance (attached) from CMS, Part D sponsors are strongly encouraged to place beneficiary-level PA requirements on four categories of prescription drugs including analgesics, antiemetics, laxatives and anxiolytics.  The PA requirements are significantly improved by the limitation to these four categories of prescription drugs versus the previous requirements for PA on all drugs.  CMS expects these four categories of prescription drugs will routinely be considered reasonable and necessary for the palliation and management of a beneficiary’s terminal illness and related conditions, and therefore are the payment responsibility of hospice providers.

Review of all medications at the time of hospice election to identify which medications are appropriate for hospice coverage versus Part D claim versus beneficiary responsibility and completion of PA continues to be very important.  This should be done by the hospice provider in collaboration with the resident, family and interdisciplinary team.  Federal regulations require Medicare hospice providers conduct and document a patient specific comprehensive assessment in writing, which must include a drug profile and state whether the medications are related or unrelated to the terminal illness and related conditions.

In addition, it continues to be important for the SNF to work collaboratively with the hospice provider and communicate medication changes timely to determine the appropriate path for coverage of the medication – Part D plan eligible (meds for condition unrelated to terminal illness or related conditions), hospice provider responsibility (meds for palliation and management of terminal and related conditions), beneficiary/resident responsibility (meds that don’t fit above conditions but resident chooses to use med or chooses med that is not on formulary and refuses to try formulary equivalent first).

Additional points for members to be aware and may be useful in communicating with hospice providers proactively and/or when confronting challenges in accessing medications in the four categories:

  • CMS strongly encourages hospice providers to provide a compassionate first fill for any medication needed by a beneficiary who is experiencing difficulty in accessing the drug.
  • An override of the rejection from the Part D sponsor is now permitted at the point of sale. Therefore, the hospice provider can contact the Part D sponsor with an oral or written statement that the drug is unrelated to the terminal illness and related conditions or the hospice provider may provide a written statement to the pharmacy or the beneficiary to transmit to the Part D sponsor.  Additional details stating why the drug is unrelated are not necessary at that time, however hospices are expected to maintain a record of the clinical basis for the statement that the drug is unrelated and provide it upon request.

Next Steps
CMS is expected to release a Q&A document intended to address any questions concerning the July 18, 2014 guidance. We will monitor CMS’ activity in this area, and will keep you informed of any updates.  In addition, we continue to work with the provider and beneficiary coalition that has been addressing this challenging issue area. If you have questions, suggestions or concerns, please contact me at nipakchi@ahca.org.  Thank you for your time and attention.

Narda Ipakchi
Director, Managed Markets
Reimbursement & Legal Affairs
American Health Care Association
Email: nipakchi@ahca.org
Phone (Direct): 202.898.6336


Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20