CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice (July 18, 2014), preamble

On June 25, 2014, CMS met with a number of stakeholder groups to discuss the implementation

of the final 2014 guidance on Part D payment for beneficiaries enrolled in the Medicare hospice

benefit (memorandum dated March 10, 2014). Beneficiary advocates, hospice providers, Part D

sponsors/pharmacy benefit managers, and pharmacies discussed their perspectives of the impact

of the policy on beneficiaries as well as the operational challenges it has posed. We thank all

participants of the meeting for taking an initial step to mutually work toward a solution to protect

beneficiaries’ access to prescription medications and the Medicare program.

Our goal for the policy we set forth in March was to ensure that the hospice and Part D programs

correctly pay for prescription drugs covered under each respective Medicare benefit while

ensuring timely access to needed prescription medications. While this remains CMS’ objective,

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 Part D

have created difficulties for Part D sponsors and hospice providers, and in some cases, barriers to

access for beneficiaries. Therefore, the purpose of this memorandum is to address both the

beneficiary access issues and the operational concerns encountered by the industry. This

guidance supersedes portions of the March 10, 2014 guidance; those portions that remain in

effect are restated in the addendum to this memorandum. In the FY 2015 Hospice Wage Index

proposed rule (79 FR 26538, May 8, 2014), we solicited comments on the definition of “terminal

illness” and “related conditions”. We received a significant number of comments representing

diverse stakeholder groups and the impact the definitions may have on those stakeholder groups.

We will consider these comments for future rulemaking.

Meanwhile, the DHHS Office of the Inspector General (OIG) released a report in June 2012

identifying situations where Medicare may be paying twice for prescription drugs for hospice

beneficiaries, who in turn could also be paying unnecessary co-payments for prescription drugs 1.

Office of the Inspector General, Department of Health and Human Services. Medicare Could Be Paying Twice for

Prescription Drugs for Beneficiaries in Hospice. June, 2012. A-06-10-00059.

As described in this report, “Hospice beneficiaries generally experience common symptoms

during the end of life, regardless of their terminal diagnosis. These symptoms include pain,

nausea, constipation, and anxiety.” We would like to highlight that the OIG worked with CMS

and the National Hospice and Palliative Care Organization (NHPCO) to identify 4 common

categories of prescription drugs that are typically used to treat these symptoms: analgesics,

antinauseants, laxatives, and antianxiety drugs.