1. Part D and Hospice Judi Lund Person, MPH Jason Kimbrel, PharmD, BCPS
Greg Dyke, RPh
Joan Harrold, MD, MPH, FAAHPM, FACP
Nancy Bridgman, Omnicare

2. Objectives Update on Part D Changes at your hospice
Admissions
Collect Part D information from beneficiary
Written materials
Giving staff the words
Medication management
Documentation of reason for unrelated
Discontinuation of meds
Review standardized form and draft instructions
FY2015 Hospice Wage Index proposed rule – Part D section
Questions

3. How did we get here? OIG report issued in 2012
Findings of $33 M in claims (FY2009) paid by Part D after beneficiary elects hospice – four classes of drugs
Additional analysis by CMS Center for Program Integrity
Ongoing and intense discussions about the “intersection between Part D and hospice” with CMS Part D and CMS Part A since summer 2013
Final guidance issued by CMS on March
Proposed regulations for hospice and Part D issued on May for FY2015

4. Components of Final Guidance
Considered to be “subregulatory guidance” without CMS enforcement
Part D and hospice confusion
“Be ready by” date of May 1, 2014 – some Part D plans implemented earlier
Repeated reference to 2014 guidance
FY2015 Hospice Wage Index proposed rule posted on May 2 references changes to Part D/Hospice intersection

5. CMS Statements
We expect drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances.
1983 Hospice final rule (48 FR 56010) was that the hospice benefit provides virtually all care for the terminally ill individual
It is a comprehensive, holistic approach to treatment that recognizes that the impending death of an individual necessitates a change from curative to palliative care.
NOTE: NHPCO continues to work with CMS on definitions and interpretations.

6. Key Issues Hospice physician’s responsibility.
Must document “why” the drug is unrelated – form calls it “Rationale for Treatment”
Can the Part D plan override the hospice’s decisions?
How will the hospice initiate communication with the Part D plan?
How can hospices begin using the standardized form?

7. Admission process changes

8. Admission Process
Talk to patients and families about the changes in Part D coverage
Evaluate pre-admission med regimen
Review patient admission packet for changes
Provide letter to patients and families describing change
Provide letter patients and families can take to pharmacy with hospice contact information
Collect information on Part D from patient/family
Collect information on preferred pharmacy

9. Finding a Patient’s Part D Plan
Three ways
Ask for the patient’s Part D card during admission
Collect patient’s insurance number, Part D plan name, any other numbers on the card and any contact phone number
PREFERRED METHOD
Contact the pre-hospice medication dispenser (preferred pharmacy) for Part D coverage information
Request that the pharmacy submit an E1 query to the CMS Transaction Facilitator, which identifies:
Name and contact information of Part D plan sponsor
Takes time, depends on pharmacy workflow
Accuracy rate = 70%

10. Referral Sources Letter explaining Part D changes
Ongoing communication about coordination with hospice
Close communication between Hospice and SNF PRIOR TO ordering medications
Expected in regulations for both hospice and SNF
Review payment responsibility
May protect SNF from difficulties with LTC pharmacy

11. Medication management

12. Four Buckets of “Relatedness”
UNRELATED,
BUT NO LONGER HELPFUL
RELATED
and
HELPFUL
RELATED, BUT NO LONGER HELPFUL – CONSIDER DISCONTINUE
UNRELATED
and
HELPFUL—
PART D
PROCESSES 26

13. Responsibility for Drugs
Hospice
Part D Plan Sponsor
Patient
All medications related to the terminal illness and related conditions
Unrelated to terminal illness and related conditions – submitted to Part D plan for processing
No longer helpful and wish to continue – related and unrelated

14. When will my hospice interact with a Part D plan?
Role of hospice PBM
Role of contracted community pharmacy
Prescriptions written by unaffiliated prescriber
If not coordinated with the hospice, will be rejected at pharmacy
Understanding Part D “processing”

15. Medication Management
Treatment decisions should not be driven by costs, as opposed to clinical appropriateness.
CMS states:
“Hospices should use thoughtful clinical judgment, with a patient-centered focus, when developing the hospice plan of care, including the recommendations for medication management.”

16. Reports from Beneficiaries
Anecdotal reports from Medicare hospice beneficiaries
They are not receiving medications related to their terminal illness and related conditions from their hospice
One reason stated – “those medications are not on the hospice’s formulary”

17. Formulary Many hospices establish a formulary
Hospice can offer an alternative to drug not on formulary
If patient declines, patient pays
Formulary drug is not working?
Hospice must provide off-formulary drug as alternative

18. Medication Review with Patients and Families
Begin the discussion
Give staff the words for the conversation
Consider timing and prognosis of patient

19. ABN for Medications No ABN Required: ABN Required:
For medications that are not reasonable and necessary and the hospice will not provide to the beneficiary
Documentation in the medical record is strongly suggested
ABN Required:
If the hospice provides and pays for a medication even though it is not reasonable and necessary, an ABN must be issued in order to charge the beneficiary

20. Beneficiary Appeal Rights
If the beneficiary feels that the Medicare hospice should cover the cost of the drug, the beneficiary may submit a claim for the medication directly to Medicare on Form CMS-1490S.
Appeal: Use if claim is denied under the appeals process set forth in part 405, subpart I.

21. Standardized form and instructions

22. Standardized Form and Instructions
Developed by National Council of Prescription Drug Plans (NCPDP) Hospice Task Group
Cooperative effort between Part D plans, NHPCO and hospice providers
“Hospice Status and Plan of Care for Medicare Part D A3 Reject Override”

23. Components of Form Unrelated medications Hospice information
Patient information
Diagnoses
Admit/discharge date
Prescriber information
Includes unaffiliated notation
Hospice PBM information
Signed by
Hospice or
Prescriber
Unrelated medications
Name and strength
Dosing schedule
Quantity per month
Rational for treatment
Medications under hospice plan of care
Determination of responsible party
Hospice
Patient

24. Patient Information Diagnoses Admit/discharge date Primary Secondary
Unrelated
Admit/discharge date

25. Medications Unrelated
Medication name and strength
Dosing schedule
Quantity per month
Rationale for treatment
Why drug is unrelated?
1-2 sentences
Must provide clinical basis

26. Instructions for Form In draft form
Feedback from hospice providers and Part D plans once the form is in use

27. Unanswered Questions
Should beneficiary give up their Part D plan when they enroll in hospice?
Can beneficiary re-enroll in Part D plan if discharged or revoke hospice benefit?
List of Part D plan phone/fax numbers for hospice contacts?
Can hospice interact with Part D plan as prescriber?
Add questions to this list…

28. Fy2015 hospice wage index proposed rule – part d included

29. FY2015 Hospice Wage Index Proposed Rule
Proposed change in filing NOE
No more than 3 days after the date of election
Propose a Notice of Termination or Revocation (NOTR)
No more than 3 days after live discharge or revocation
Considering requiring Part D sponsors to accept NOE and NOTR information as use for coverage until official CMS notification is received

30. New Proposed Definitions
Terminal illness
Related conditions
CMS asks for comments on definitions
Definitions, when final, will guide Part D coverage for hospice patient medications

31. Independent Review Process
CMS considering
Separate and distinct from the enrollee appeals process
Independent Review Entity (IRE) decision would be binding on both the Part D sponsor and the hospice

32. Resources NHPCO web page on Part D and Hospice
Compliance Guide
Sample Letters
Latest information