CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Hospice—Final 2014 Guidance (Mar. 10, 2014), § Implications for Beneficiaries: Beneficiary Fee-for-Service Claims and Appeals

Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide

because it’s not reasonable and necessary for the palliation and management of the terminal

illness and related conditions. The cost of such a medication, which is not reasonable and

necessary for the management of the terminal illness or related conditions, would be a

beneficiary liability. If the hospice does not provide the medication, the hospice is not obligated

to provide any notice of non-coverage (including the Advance Beneficiary Notice of Non-coverage or ABN). If the hospice provides the medication even though it is not reasonable and

necessary, it must issue an ABN in order to charge the beneficiary for the medication.

Regardless of whether or not the hospice furnishes the drug, if the beneficiary feels that the

Medicare hospice should cover the cost of the drug, the beneficiary may submit a claim for the

medication directly to Medicare on Form CMS-1490S. If the claim is denied, the beneficiary

may file an appeal of that determination under the appeals process set forth in part 405, subpart I.

If the beneficiary desires to continue taking drugs that are not covered by Medicare Part A or

Part D, then the hospice must fully inform the beneficiary of his or her financial liability.

Beneficiaries who disagree with such determinations may continue raising these issues through

the Medicare fee-for-service appeals process if the determination relates to Part A or B coverage

and the Part D appeals process if the determination relates to Part D coverage. Beneficiaries may

also submit quality of care complaints to a Quality Improvement Organization when the

beneficiary prefers a non-formulary drug because, for example, it’s believed to be more

efficacious than the formulary drug prescribed by the hospice.