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"Medicare Eases Rule for Hospice Patient Medication" by Elaine Brady, HSM Board Member

Medicare initiated three regulatory changes for hospice organizations this year. One that went into effect on May 1st mandated that all Medicare beneficiaries on hospice would automatically need prior approval by hospice and their physician in order to have Medicare Part D pay for any medication directly. While well meaning, this one change in regulation had widespread negative consequences for hospice patients and families nationwide. At Hospice of Southern Maine, our Clinical Supervisors were fielding dozens of calls daily from frustrated and upset families who were being told that they would have to pay out of pocket for covered Part D medications because the Medicare electronic system said they were “denied.” Even though hospices were scurrying to secure and fax necessary signatures of approval to the Part D pharmacy, many Part D pharmacies were not prepared to accept or process the piles of paperwork being created. Confusion and anxiety abounded until patient advocates and national organizations were able to convince Medicare to “rethink” the new regulation.

In response, this past Friday, July 18, 2014 Medicare significantly eased its rules for insurance coverage of medications for many thousands of hospice patients in response to this intense criticism that had reached the ears of Congress. The new policy change now eliminates 95% of the cases in which hospice patients need prior approval from an insurance company to get coverage for their drugs. Instead of requiring prior approval for ALL medications, Medicare is now only requiring this approval for coverage of drugs for conditions unrelated to the terminal illness.

The new policy change now only requires prior approval from Medicare Part D insurers for just four classes of drugs: analgesics, anti-nauseants, laxatives and anti-anxiety drugs. These drugs are commonly used in caring for hospice patients, who have been identified by physicians as individuals with a life expectancy of six months or less. Drugs that a hospice patient might be taking for a chronic condition, unrelated to the terminal diagnosis, will once again be covered under the Part D Medicare benefit without prior approval or tons of paperwork. In other words, the tedious process which began on May 1, 2014 that left many prescriptions unfilled due to the length of time to get paperwork completed and the inability for families to afford the drugs without insurance coverage, has in essence, gone away. In my humble opinion… a victory for rational thinking! For more information, visit Centers for Medicare & Medicaid Services.

Written by Elaine Brady, RN, MHSA, HSM Board Member

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