Hospice Medications & Medicare Part D

1. Hospice Medications & Medicare Part D Claudia Baker, RN, BS (Delta Health Technologies)

2. Ever changing tides! Are you keeping up with the tide chart?? Introduction

3. Why the Focus on Medications? CMS Memorandum: March 2014 Revisions to Memorandum: July 2014 Coverage of Medications Current Prior Authorization Process NDC versus HCPCS Codes Infusion Pump Coverage NOE, NOTR Timely-Filing Requirements Summary Session Agenda

4. Why the Scrutiny? In June 2012, the Office of the Inspector General (OIG) released a report that said Medicare may be paying twice for prescription drugs for hospice beneficiaries, who in turn could also be paying unnecessary co-payments for drugs.

5. CMS March 2014 Memorandum Hospice is responsible for covering all drugs or biologicals for the palliation and management of the terminal and related conditions. Drugs and biologics covered under the Medicare Part A per-diem payment to a hospice program, therefore, are excluded from coverage under Part D. For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal illness or related conditions; in other words, the drug is unrelated to the terminal prognosis of the individual.

6. CMS March 2014 Memorandum “We expect drugs covered under Part D for hospice beneficiaries will be unusual and exceptional circumstances. Therefore, the sponsor should place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are coverable under Part D.” “Because these PAs are necessary to establish whether the drug may be covered under Part D at all, a Part D enrollee’s transition benefit has no impact on applying these edits.”

7. Impact!

8. Impact of the March 2014 Memorandum “We recognize that the operational challenges associated with prior authorizing all drug for beneficiaries who have elected hospice to determine if they are coverable under Part D have created difficulties for part D sponsors and hospice providers, and in some cases, barriers to access for beneficiaries.”

9. How Did It Impact You?

10. Revised Guidance for Part D Due to patient access and operational issues, instead of requiring the Prior Authorization (PA) for all drugs for hospice beneficiaries, CMS strongly encourages sponsors (MA plans) to place beneficiary-level PA requirements only on 4 categories of prescriptions drugs: • Analgesics • Antinauseants (antiemetics) • Laxatives • Antianxiety drugs (anxiolytics)

11. Revised Guidance for Part D CMS expects Part D sponsors to identify the national drug codes (NDC) for drugs included within these 4 categories. The expectation is they are NOT to place hospice PA requirements on other categories of drugs (except routine utilization review measures). These drugs are the least likely to be subjected to disputes concerning payment and any barriers to beneficiary access will be minimized.

12. In the revised guidance, hospices are to report a beneficiary’s Medicare hospice election to the Part D sponsor and identify any drugs in the 4 categories that are unrelated to the terminal illness and/or related conditions PRIOR to the submission of the claim. This information is to be used by the Part D plan to use the appropriate override code for the PA. How to Report Medications

13. Medication information obtained through the comprehensive assessment, including whether the meds are related or unrelated to the terminal illness and related conditions, should be provided to the Part D sponsor proactively. This means BEFORE a beneficiary presents a prescription for fill. If not possible, the hospice should provide the information to the Part D sponsor the information after they are contacted by the plan during the PA process. How to Report Medications

14. If a claim is rejected by a Part D sponsor due to a PA, the pharmacy or beneficiary may contact the provider for a statement that the drug is unrelated to the terminal illness and related conditions. The provider can provide this information orally or in a written statement to the pharmacy or the beneficiary to provide to the Part D plan folks. The sponsor is to accept this information to override the rejection without requiring that the beneficiary, the beneficiary’s representative, or others on their behalf, request a coverage determination. A hospice provider cannot request a coverage determination on behalf of the beneficiary. Prior Auth for Drugs in the Fab 4

15. In documenting part D coverage of the Fab 4 categories, a statement indicating the drug is unrelated to the terminal illness and related conditions is sufficient. The statement may be as simple as a “U” or “”unrelated”. Hospices are expected to maintain a record of the clinical basis for the statement and provide it upon request. CMS strongly encourages hospice providers to provide compassionate first fill for any medication needed by a beneficiary who is experiencing difficulty in accessing the drug initially. Prior Authfor Drugs in the Fab 4

16. The Part D sponsors are instructed to use specific codes to override the standard PA process. They are as follows: A3: This product may be covered under hospice – Medicare A 75: Prior Authorization Required Clearly stated hospice responsibilities 569: Provide Notice: Medicare Prescription Prior Authorization Codes

17. More Clarification • To get Part D coverage, it cannot be a drug that is covered by the hospice benefit (Medicare Part A). • OTC drugs are excluded from the Part D benefit. • Drugs prescribed for the beneficiary that are unrelated to the terminal illness and related conditions continue to be subject to the Part D formulary management practices, including quantity limitations, step therapy, and prior authorizations.

18. In addition to the beneficiary-level hospice PA for determining whether the drug in the 4 categories is coverable under Part D, a plan sponsor may have a utilization management (UM) edit on the drug that must also be satisfied. Keep in Mind….

19. NDC versus HCPCS Non-injectableprescription drugs are reported with revenue code 0250 and the NDC.  Injectableprescription drugs are reported with revenue code 0636 and the HCPCS code.  VS

20. National Drug Codes • The NDC is a code set that identifies the vendor (manufacturer), product and package size of all drugs and biologics recognized by the FDA. • The 3 segments of the 11-digit NDC identify the labeler, the product, and the commercial package size.   • In addition to the actual NDC, you will also have to report the qualifier (electronic claims only), the quantity dispensed, and the unit qualifier.

21. CMS reissued CR8358 on January 31, 2014. The revised CR states, “Hospice agencies shall report infusion pumps (a type of DME) on a line-item basis for each pump and for each medication fill and refill. The hospice claim shall reflect the total charge for the infusion pump for the period covered by the claim, whether the hospice is billed for it daily, weekly, biweekly, with each medication refill, or in some other fashion. The hospice shall include on the claim the infusion pump charges on whatever basis is easiest for its billing systems so long as, in total, the claim reflects the charges for the pump for the time period of that claim." Infusion Pump Guidance

22. How do we report infusion pump and medication in a GIP setting when it’s included in the GIP rate we pay to the hospital with which we contract? Report all prescription medications and infusion pumps provided under the hospice benefit, regardless of level of care or site of service. We suggest you coordinate with those providers you contract with, as they may need to modify their billing to the hospice to assist the hospice in meeting this new requirement. Since the hospice is still responsible for its patients receiving GIP in a contracted facility, it should know what medications were provided and if an infusion pump was used.  Infusion Pumps Q & A

23. When reporting compounded medications, hospices should report each prescription drug that is part of the compound on a separate line item using revenue code 0250 along with the NDC number. Compounded Medications

24. TheTable of Drugs is available on the Centers for Medicare & Medicaid Services (CMS) website atwww.cms.gov List of HCPCS: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2014-Drugs-Table.html?DLPage=1&DLSort=0&DLSortDir=descending NDC Directory: http://www.fda.gov/drugs/informationondrugs/ucm142438.htm Resource Lists

25. Timely Filing of Notice of Election • A timely-filed NOE must be filed within 5 calendar days after the hospice admission date. • The date of posting to the CWF is not a reflection of whether it is considered timely. • If it is not filed timely, Medicare will not cover and pay for gap days. They are provider liability – that’s you!

26. Timely Filing of the NOTR As of October 1, 2014, CMS will require that the hospice send the NOTR within five days after the termination IF the final bill has not been sent in that time frame.  Following is the description from CR8877: If a hospice beneficiary is discharged alive or if a hospice beneficiaryis discharged aliveorifahospicebeneficiaryrevokes the election ofhospice care, thehospiceshall fileatimely-filed NoticeofElection Termination / Revocation (NOTR)usingtypeofbill 8xB, unless it has alreadyfileda final claim.  A timely-filed NOTRis aNOTRthat is submitted tothe Medicarecontractor andaccepted bytheMedicare contractorwithin 5 calendardays aftertheeffectivedate ofdischargeor revocation.

27. Changes to the recent changes Feedback to CMS does help! Documentation of relation to terminal illness and conditions. NDCs, HCPSC and other acronyms NOE, NOTR timely-filing changes Summary

28. Question and Answer Session