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Centers for Medicare and Medicaid Services Change the Rules, Again

medications for hospice patients

The protests of patient advocates and support groups have finally been acknowledged by the Centers for Medicare and Medicaid Services. The CMS has revised earlier guidance that required hospice patients covered by Medicare Part D to get prior authorization of all their drugs.

Medicare’s hospice benefit sometimes pays for medications under Part D provisions. To prevent this from happening, CMS issued guidance in March 2014, issued rules requiring Part D plans to initially deny payment for all prescribed medications for hospice patients, forcing terminal patients or their families to appeal the denials in order to get Part D sanctioned payment for their medications. Many  of these medications were being taken before they enrolled in hospice.

Transferring this burden of payment and appeals to the patient is illogical and immoral, said the Center for Medicare Advocacy. The Center joined more than two dozen other organizations in calling on CMS to revise its guidance with a more suitable solution.

The protests of these advocacy organizations were heard. On June 25, 2014, CMS met with a number of these groups to discuss the implementation of the new guidelines. On July 18, 2014, the CMS issued new guidance that contradicts portions of the earlier revised rules.

Now, instead of requiring prior authorization for all medications, CMS will only “strongly encourage” Part D programs to place prior authorization requirements on four categories of prescription drugs that are used to treat symptoms during the end of life. These four include analgesics, antinauseants, laxatives and antianxiety drugs.

CMS stated in an announcement that “We recognize that the operational challenges associated with prior authorizing all drugs for beneficiaries who have elected hospice to determine whether the drug  is coverable under Park D have created difficulties for Part D sponsors and hospice providers, and in some cases, barriers to access for beneficiaries.”

CMS called the replacement guidance “significantly better than the original.” However, at the same time, CMS stated that it still relies upon the goodwill and prompt diligence of hospice providers, pharmacies and Park D Plan Sponsors to ensure Medicare beneficiaries do not lose access to medications necessary to prevent pain, nausea, constipation and anxiety.”

The Center also expressed concern that there are no time frames to ensure that these players act expeditiously and there is no real appeal process for terminally ill patients who medications are not meeting their needs.

For the CMS memorandum containing the new guidance, go to:

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