Update: CMS May NOT Force the Dying to Spend Their Final Days Jumping Through Hoops to Get Needed Medications

Following an outcry from patient advocates, the Centers for Medicare and Medicaid Services (CMS) has revised earlier guidance that required hospice patients covered by Medicare Part D plans to get prior authorization of all their drugs.

As previously reported on May 14, 2014, Part D plans sometimes pay for medications that should be covered under Medicare’s hospice benefit.  In an effort to prevent this, in March CMS issued guidance requiring Part D plans to initially deny payment for all prescribed medications for hospice patients, forcing dying patients or their families to appeal the denials in order to get Part D payment for their medications, many of which they were taking before they enrolled in hospice. 

“This burden-shifting to the dying patient is illogical and immoral,” concluded the Center for Medicare Advocacy.  On June 11, the Center joined 26 other organizations in calling on CMS to replace its guidance with a more suitable solution.

Their concerns were heard.  On June 25, 2014, CMS met with a number of these groups to discuss the implementation of the guidance, and on July 18 the agency issued new guidance that supersedes portions of the earlier guidance.  Now, rather than requiring prior authorization for all medications, CMS will only “strongly encourage” Part D programs to place prior authorization requirements on four categories of prescription drugs that are typically used to treat symptoms during the end of life: analgesics, antinauseants, laxatives, and antianxiety drugs.  In making the change, CMS said “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."

“This action by CMS will bring marked relief to hospice patients and their providers who have been dealing with the previous policy under which all drugs processed through Part D for hospice patients were subject to prior authorization,” said Andrea Devoti, board chair of the National Association for Home Care & Hospice, said in a press release.

However, the Center for Medicare Advocacy was somewhat more restrained in its praise.  While calling the replacement guidance "significantly better than the original," the Center said CMS still “relies upon the good will and prompt diligence of hospice providers, pharmacies, and Part D Plan Sponsors to ensure Medicare beneficiaries do not lose access to medications necessary to prevent pain, nausea, constipation, and anxiety.”  The Center also expressed concern that there are no time frames to ensure that these players act expeditiously, and there is no real appeal process for terminally ill patients whose medications are not meeting their needs. 

For the CMS memorandum containing the new guidance, click here.