Hospice Guidance Turns 180 Degrees

After 70 Senators signed a protest bill and the hue and cry from hospice providers, patients and prescribers got too loud, CMS rescinded its’ previous regs for hospice patients and published new guidance on 7-18-14. Previous guidance required health plans to place prior authorization edits on all medications after a member was identified as being a hospice patient. So, all the medications that the member was previously receiving under their Part D benefit were denied at point of sale. This caused a significant hardship to hospice providers who many times had to pay for the hospice member’s medications. The philosophical and medical issue continues to be what medications should be continued and which medications should be discontinued when members are in their hospice benefit. Should antihypertensive, antihyperlipidemic, diabetes and other chronic medications be continued for hospice patients? Rational and substantive arguments exist for the continuation of some chemotherapy medications which keep tumor growth in check and are considered to be palliative for some patients.

The new guidelines require plan sponsors to place beneficiary level prior authorization requirements on four categories of prescription drugs:

• Analgesics
• Antinauseants (antiemetics)
• Laxatives
• Antianxiety drugs (anxiolytics)

These categories are assumed to be “related to the terminal illness and/or related conditions”. Hospice providers will provide these medications. Plan sponsors are expected to continue to provide other medications which may have CMS approved utilization management edits including quantity limits, step therapy and prior authorization. Retrospective review is expected to determine whether other medications were “unrelated to the hospice beneficiary’s terminal illness”.

Resources

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