CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice (July 18, 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. f 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.