Transcript Part D and Hospice

Part D and Hospice
Judi Lund Person, MPH
Jason Kimbrel, PharmD, BCPS
Greg Dyke, RPh
Joan Harrold, MD, MPH, FAAHPM, FACP
Nancy Bridgman, Omnicare
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
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 10 2014
• Proposed regulations for hospice and Part D issued on
May 2 2014 for FY2015
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
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.
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?
ADMISSION PROCESS CHANGES
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
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%
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
MEDICATION MANAGEMENT
Four Buckets of “Relatedness”
RELATED
and
HELPFUL
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RELATED, BUT
NO LONGER
HELPFUL –
CONSIDER
DISCONTINUE
UNRELATED
and
HELPFUL—
PART D
PROCESSES
UNRELATED,
BUT NO
LONGER
HELPFUL
Responsibility for Drugs
Part D Plan
Hospice
Sponsor
All medications Unrelated to
related to the terminal illness
terminal illness and related
and related
conditions –
conditions
submitted to
Part D plan for
processing
Patient
No longer
helpful and
wish to
continue –
related and
unrelated
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”
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.”
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”
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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
Medication Review with Patients and
Families
• Begin the discussion
• Give staff the words for the conversation
• Consider timing and prognosis of patient
ABN for Medications
• No 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
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.
STANDARDIZED FORM AND
INSTRUCTIONS
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”
Components of Form
• 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
Patient Information
• Diagnoses
– Primary
– Secondary
– Unrelated
• Admit/discharge date
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
Instructions for Form
• In draft form
• Feedback from hospice providers and Part D
plans once the form is in use
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…
FY2015 HOSPICE WAGE INDEX
PROPOSED RULE – PART D
INCLUDED
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
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
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
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Resources
• NHPCO web page on Part D and Hospice
• http://www.nhpco.org/regulatorycompliance-hospices/part-d-and-hospice
• Compliance Guide
• Sample Letters
• Latest information