Medicare backs off hospice drug hurdles after criticism

Medicare is backing away from a rule requiring special authorization for drugs used in hospice care after advocates said the limits would harm terminally ill patients.

The Centers for Medicare and Medicaid Services (CMS) released additional guidance Friday recommending "prior authorization" for only four classes of drugs instead of all of them.

ADVERTISEMENT
“Based on discussions with stakeholders, we are adjusting our rules so that beneficiaries enrolled in hospice will continue to have access to their medications," CMS spokesman Ray Thorn said in a statement.

The original rules, finalized in March, asked plan sponsors in Medicare Part D to require "prior authorization" for drugs used in hospice care to ensure the correct division of Medicare paid the bill.

The program's inspector general had raised concerns that Part D was paying for drugs for people in hospice when the medications should have been covered by Part A.

In the revised guidance, the CMS is asking Part D plans to establish "prior authorization" for only painkillers, anti-nauseants, laxatives and anti-anxiety drugs used by hospice patients.

The agency is trying to ensure that hospice providers bill Part A for the drugs, which are almost always covered under that benefit, and not Part D.

The CMS also specified a special pathway for hospice providers who want to prescribe the drugs to hospice patients for reasons unrelated to terminal illness.

In that case, prescribers can bill Part D by stating the drugs are "unrelated" to hospice care, and do not need to provide a clinical justification for their decision.

"CMS expects the number of [Medicare] Part D claims for drugs in these four categories to be very few and as a result, barriers to beneficiary access should be minimized," the agency stated in a memo.

Advocates have been pressuring lawmakers to push the agency to withdraw its requirement.