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CMS Seeks Answers Related to Part D Plans and Hospice Payments

In the 2015 proposed hospice rule released on May 2, the Centers for Medicaid and Medicare Services (CMS) seeks suggestions on the best way for hospices to coordinate with Part D plans regarding payments for certain prescriptions.

CMS is considering requiring Part D sponsors to communicate with hospices to determine coverage for drugs "whenever a coverage determination process is initiated or a hospice furnishes information regarding a beneficiary's hospice election and/or drug profile." Coordination would occur after the hospice contacts the sponsor to report information concerning a hospice election and/or drug profile. It also would occur after the beneficiary, the beneficiary's appointed representative or the prescriber initiates a coverage determination request.

Beginning this month, hospices should provide "a coherent clinical explanation" about why the drug is unrelated to a patient's terminal condition in order to get paid by Part D.

Part D sponsors receiving claims for drugs for hospice beneficiaries will automatically send requesting pharmacies a "reject code." The pharmacy will inform the patient if the medication is not covered or if the medication is unrelated to the hospice principal diagnosis and related conditions. Part D will not pay for those drugs unless the hospice or prescriber explains the drug is medically necessary but unrelated to the illness.

CMS previously indicated that it would establish a process whereby an independent reviewer can ask to examine disputed claims to determine whether they fall under Part A or D. That additional step in the appeals process established by regulation won't be available in 2014.


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