(This article previously appeared on HealthWithAging.com.)
Medicare eased significantly on Friday, July 18, 2014 its rules for insurance coverage of medications for many thousands of hospice patients, responding to intense criticism from patient advocates and members of Congress.
The new policy should eliminate 95 percent of the cases in which hospice patients need prior approval from an insurance company to get coverage for their drugs, according to participants in a Medicare briefing.
The move applies to coverage of drugs for conditions unrelated to the terminal illness.
How the New Rule Works
For example, a hospice patient who is dying from cancer also might be taking drugs to deal with his arthritis and congestive heart failure. The policy in effect since May required patients to get prior approval from their Medicare Part D insurer before filling a prescription for these medications for conditions other than the terminal illness. This became a tedious process, and many prescriptions went unfilled because it took a long time to get prior approval and the families might not be able to afford the drugs without insurance coverage.
Patients already suffering through a terminal illness couldn’t get the drugs they needed to deal with their pre-existing chronic conditions on a timely basis, and this was causing widespread distress, according to a story on Thursday July 17, 2014 by HelpwithAging.com.
Which Drugs Are Covered
The new policy will require prior approval from Medicare Part D insurers for just four classes of drugs: analgesics, anti-nauseants, laxatives and anti-anxiety drugs, Medicare said.
These drugs “are nearly always covered under the hospice benefit,” the Center for Medicare and Medicaid Services (CMS) said in a policy statement issued Friday. That means they are commonly used in caring for hospice patients, who have been identified by physicians as individuals with a life expectancy of six months or less.
Medicare “expects the number of Part D claims for drugs in these four categories to be very few and as a result, barriers to beneficiary access should be minimized,” CMS said. “In addition, when the hospice provider or prescriber believes a drug in one of the four categories is unrelated to the terminal illness or related condition, they may satisfy the prior authorization requirement by simply stating the drug is ‘unrelated,’ rather than, as in prior guidance, providing a clinical justification for why it is unrelated.”
The change in policy “will help tremendously,” said Theresa Forster, vice president for Hospice Policy & Programs at the National Association for Home Care & Hospice.
Some Continuing Concerns
“We do have continuing concerns about making sure the process plays out as intended, so that patients are able to get their drugs at point of sale without delay,” she added. “But this will significantly reduce the number of drugs at must go through PA [prior approval].”
This new policy should solve most of the difficulties facing hospices and family members of patients, who had to obtain prior approval for drugs that the patients had been taking before they entered hospice.
Hospice workers and family members had been spending many hours on the phone with Part D insurers and with physicians trying to get authorization to use drugs that had previously been covered on a routine basis.
(MORE: Find Out More About Hospice Care)
Friday’s announcement “will greatly relieve the stress that patients and families, as well as providers, were experiencing under the prior flawed process,” said Jonathan Keyserling, senior vice president and counsel in the Office of Health Policy for the National Hospice and Palliative Care Organization (NHPCO) and executive director of the Hospice Action Network (HAN), the advocacy arm of the NHPCO.
If Slowdowns Occur
However, there still will be occasions when the process may slow down as insurers ask for prior approval for medications they consider unrelated to hospice activity. If that happens, CMS indicated it will “encourage hospice providers to offer compassionate ‘first fill’ for any medication for which the beneficiary experiences difficulties at the point of sale,” said David Lipschutz, a senior attorney at the Center for Medicare Advocacy.
That means the hospice will cover the drug and get reimbursed later, so the patient doesn’t have to walk away from the pharmacy without her medications, according to Lipschutz.
Need for a Permanent Fix
But the controversies surrounding coverage still need a permanent solution, Lipschutz said.
The announcement by CMS is considered guidance for hospices and insurance companies, an interim policy running through 2015, or until CMS develops a permanent rule on this issue. It has become a contentious regulatory debate, with Medicare having accused some hospices of improperly billing the government for drug costs.
The policy announced by CMS should prevent some of the cases of patient suffering reported in Thursday’s Helpwithaging.com story and provided by the National Association for Home Care & Hospice. Examples:
Cadillac, Mich. “Client on hospice for colon cancer; being denied insulin which is NOT related to the colon cancer and is NOT paid by the Hospice for the palliation or symptom management of colon cancer. Delay in getting insulin to the patient and an out of pocket expense of $373.75 for a 25-day supply of insulin.”
Cincinnati, Ohio. “Part D would not approve the meds and the pharmacy would not refill even though the PA [prior authorization] form was completed. Patients ran out of their medications and will go to the hospital.”
Oklahoma City, Okla. “Patient is on hospice for tongue cancer. He has COPD and uses Symbicort and Proair. He was unable to refill these meds…. Hospice sent PA [prior authorization] to [insurance company] they would not accept it… meds were prescribed by PCP [primary care physician.] Pt [patient] went without these Rx’s for a week. This incident caused undue stress to the pt and his family, not to mention physical ailment from going without meds for a week. This took up a significant amount of time for the hospice on repeated phone calls, paperwork and faxes.”
Wallingford, Conn. “This patient is unable to receive his medication that controls his high blood pressure and he is now at risk for a stroke. He also has been unable to get his GERD medication and he is having pain.”