New Medicare guidance went into effect today to prevent duplicate payments for drugs beneficiaries receive while in hospice care. Drugs related to palliative, end-of-life care are covered by the hospice benefit, while other drugs are supposed to be covered by Part D. When hospice care-related drugs are covered by Part D, Medicare is essentially paying twice for the same prescription. A 2012 OIG investigation found that in 2009, Part D plans paid more than $33 million for drugs that should have been covered by the hospice benefit, and beneficiaries paid nearly $4 million in copayments.
The new rule requires Part D sponsors to “place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are coverable under Part D.” Following standard PA procedures, after the initial claim is rejected, the patient or doctor, with the hospice provider’s agreement, must explain why the drugs are not related to hospice care. Sponsors must then decide whether to cover the drugs, though CMS has not yet provided objective criteria for payment determinations.