Healthcare Law Blog

Update: CMS Issues Revised Guidance on Hospice & Part D Prior Authorization Process

A few weeks ago, we discussed CMS’ newly-issued guidance establishing a prior authorization process for Hospice and Part D providers (read more here). As our previous blog post emphasized, soon after its March 10 implementation, advocacy groups, Hospice associations, and Members of Congress began urging CMS to suspend the process. According to opponents, the prior authorization requirement creates a barrier for beneficiaries to access necessary medications and leaves them to navigate complicated payor disputes in the midst of their terminal illnesses.

On July 18, 2014, CMS responded to this industry outcry with revised guidance (“RG”). The RG supersedes portions of CMS’ March 10 guidance to address operational and beneficiary access concerns raised by industry advocates. “Our goal for the policy we set forth in March was to ensure that the hospice and Part D programs correctly pay for prescription drugs covered under each respective Medicare benefit while ensuring timely access to needed prescription medications,” the RG states. “[W]e recognize that the operational challenges associated with prior authorizing all drugs for beneficiaries who have elected hospice to determine whether the drug is coverable under Part D have created difficulties for Part D sponsors and hospice providers, and in some cases, barriers to access for beneficiaries.”

The RG instructs Part D sponsors to require prior authorization for only four categories of drugs: analgesics, antinauseants, laxatives, and antianxiety drugs. According to CMS, medications in these four drug classes are generally related to the patient’s principal terminal diagnosis and will be paid by Hospice in most instances. In addition, the RG encourages the use    of a standardized form to replace the list of prior authorization data elements previously identified by CMS. Find a copy of the form here.

While CMS indicates that these changes are effective immediately and strongly encourages plans to implement the RG as soon as possible, plans must implement the guidance by Oct. 1, 2014. If you are a Hospice provider and have questions about the RG

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This article does not constitute legal advice.