Shaida Talebreza, MD HMDC
Editor’s note: In the fall 2014 Quarterly Clinical Pearls Article “Goals-of-Care Discussions for Deprescribing,” Dr. Talebreza shares ways (and even a sample script) for healthcare providers to engage patients in decision making regarding medication deprescribing. The following is a tool, created by Dr. Talebreza, to help hospice professionals to determine the category of the hospice medication and to initiate a conversion with the patient and his or her family about the topic. Additionally, Dr. Talebreza has provided further information regarding recent CMS guidance. How have you approached this situation or what questions might you have? We welcome you to leave your comments below.
On March 10, 2014, CMS issued guidance to the hospice community and Medicare Part D Sponsors on Part D payment for drugs for beneficiaries enrolled in hospice. On July 18, 2014, CMS issued revised guidance .
Drugs Covered Under the Hospice Benefit
The hospice plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. As such, there may be some medications that were used prior to the hospice election that will continue as part of the hospice plan of care, and would be covered under the Medicare hospice benefit, if those drugs are necessary for the palliation and management of the terminal illness and related conditions (CMS, March 10, 2014).
We expect that Medicare hospice providers will continue to provide all of the medications that are reasonable and necessary for the palliation and management of a beneficiary’s terminal illness and related conditions (CMS, July 18, 2014).
Drugs That Are a Beneficiary Liability
There may be some drugs that were for the treatment of the terminal illness or related conditions prior to the hospice election that will be discontinued upon hospice election, as it has been determined by the hospice interdisciplinary group, after discussions with the hospice patient and family, that those medications may no longer be effective in the intended treatment, or may be causing additional negative symptoms in the individual. These medications would not be covered under the Medicare hospice benefit, as they would not be reasonable and necessary for the palliation of pain or symptom management. If a beneficiary still chooses to have these medications filled through his or her pharmacy, the costs of these medications would then become a beneficiary liability for payment and not covered by Part D. These medications would not be covered by Part D because their further coverage is prohibited under Medicare (CMS, July 18, 2014).
Similarly, if a beneficiary requests a drug for his or her terminal illness or related conditions that is not on the hospice formulary and the beneficiary refuses to try a formulary equivalent first; or the drug is determined by the hospice provider to be unreasonable or unnecessary for the palliation of pain or symptom management, the beneficiary may opt to assume financial responsibility for the drug. However, no payment for the drug will be available under Part D (CMS, July 18, 2014).
When a drug is determined by the hospice provider to be the beneficiary’s responsibility, Part D has no payment responsibility and payment coordination is not an issue (CMS, July 18, 2014).
Drugs Covered Under Part D for a Beneficiary Who Has Elected Hospice
For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal illness or related conditions; in other words, the drug is unrelated to the terminal prognosis of the individual (CMS, March 10, 2014).