Guidance on Part D Coverage of Hospice Drugs
CMS has issued a final memo providing guidance for Part D sponsors and hospices as it relates to payment for drugs for hospice beneficiaries in 2014. The effective date of this policy clarification is May 1, 2014 and will be applied prospectively. When a beneficiary (or authorized representative) has elected the hospice benefit, the hospice is responsible for covering all drugs or biologicals for the palliation and management of the terminal and related conditions. Drugs and biologics covered under the Medicare Part A per-diem payment to a hospice program, therefore, are excluded from coverage under Part D.
For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal illness or related conditions. CMS expects drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances. Therefore, the sponsor should 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. CMS expects Part D sponsors should implement processes to handle payment resolution directly with hospice providers and beneficiaries without requiring the pharmacy reverse and rebill the original claim in the retail setting. However, whenever the network pharmacy involved is also the hospice pharmacy, as is often the case with long-term care pharmacies, reverse and rebill may be the most appropriate approach.
The guidance from CMS, a ‘Frequently Asked Questions’ document form CMS, as well as a summary is available on the members-only section of the LTC Division website, under Other Issues of Interest to LTC.