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Medicare Modifies Controversial Hospice Drug Rule

WebMD News from Kaiser Health News

By Susan Jaffe

Fri, Jul 18 2014

In response to strong criticism, Medicare officials are modifying rules intended to prevent the agency from paying twice for the same prescriptions for seniors receiving hospice care.

Under the rules that took effect in May, hospice patients or their families could not fill prescriptions through their Part D drug plans until first confirming that the prescriptions were not covered by hospice providers.  Drugs related to palliative and comfort care are supposed to be covered under the fixed rate payments to the hospice.

Medicare announced Friday that the rules would be revised so that the additional authorization would be required for only four types of medications:  pain relievers, anti-nauseants, laxatives, and anti-anxiety drugs that are “nearly always” considered hospice-related.

“Medicare really tried to address our concerns quickly and effectively,” said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy. “They really did a good job and even though it’s not perfect, it’s so much better.”

The four drug categories were identified in a 2012 investigation by the Department of Health and Human Services’ inspector general. Investigators found that Part D prescription drug plans paid more than $33 million in 2009 that should have probably been covered by the hospice benefit. Part of those overpayments also were for  prescription drugs used to treat pulmonary problems and amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease. Beneficiaries paid nearly $4 million in copayments, the report by the Department of Health and Human Services’ inspector general found.

“Based on discussions with stakeholders, we are adjusting our rules so that beneficiaries enrolled in hospice will continue to have access to their medications while balancing recommendations by the Inspector General meant to safeguard the Medicare program,” said Medicare spokesman  Raymond Thorn.

Medicare officials revised the rules after meeting in late June with beneficiary advocates, hospice providers, insurers offering Part D drug plans and pharmacists.

Medicare generally pays drugs for diabetes, heart disease or other chronic conditions still used by hospice patients but not directly related to their terminal illness. Those are covered by Medicare Part D prescription drug plans, which are heavily subsidized by Medicare, with beneficiaries picking up roughly 25 percent of the bill.

Contact Susan Jaffe at

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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