Your Weekly Medicare Consumer Advocacy Update
Changes Proposed to the Way Medicare Hospice Benefit Works with Part D
CMS Proposes Changes to How the Medicare Hospice Benefit Works With Part D
The Centers for Medicare & Medicaid Services (CMS) recently released proposed changes to the Medicare hospice benefit. Among these are proposals to clarify how the hospice benefit works with Medicare Part D prescription drug coverage. The Medicare hospice benefit, under Part A, covers prescription drugs that treat the beneficiary’s terminal illness or any related conditions to that illness. Prescription drugs for any non-related conditions should continue to be covered by the beneficiary’s Part D plan.
CMS is looking for comments on the proposed rule which seeks to clarify how hospice and Part D work together. Under this proposal, plans will be required to impose prior authorization on all prescriptions for beneficiaries in hospice care. To meet the prior authorization requirement, the prescribing doctor and the hospice agency will be required to demonstrate to the Part D plan that the drug is unrelated to the beneficiary’s terminal illness. Specifically, CMS proposes creating a standardized process for determining which organization is responsible for covering a drug, and creating a clearer definition for “terminal illness” and for “related conditions.”
While the proposed policy serves an important purpose—ensuring that the right entity, the hospice (Part A) or the Part D plan, pays for the right medicines—the proposed policy may place an undue burden on beneficiaries, particularly when prior authorization is denied. In these cases, beneficiaries may need to work through the Medicare Part D appeals process—a complicated, multi-step system that many seniors and people with disabilities struggle to navigate. Medicare Rights will continue to analyze the proposed rule and provide comments to ensure that hospice patients are not inadvertently harmed by the new prior authorization requirements.
Health Care Spending Slowing for Older Adults, But Costs Remain High
According to a report released this week by CMS, among older adults, average annual growth in personal health care spending per person is lower than it is for any other age group. From 2002 to 2010 the per person personal health care spending growth rate for medical goods and services among older adults was 4.1 percent.
While this is good news, the study also found that older adults’ spending on health care costs remains high compared to other age groups. In 2010, spending per older adult was about three times more than the average working adult—about $18,400 compared to $6,100—and about five times more than children—$18,400 compared to $3,600.
Why is health care spending growing at lower rates for older adults? According to CMS, slower Medicare spending overall and slow growth in spending for nursing care and continuing care retirement communities both played a role.
Volume 5, Issue 18
Medicare will help pay for your hospice care if you meet all of the following criteria:
- You have Part A
- The hospice medical director (and your doctor, if you have one) certify that you have a terminal illness (your life expectancy is six months or less)
- You sign a statement electing to have Medicare pay for palliative care such as pain management, rather than care to try to cure your condition
- Your terminal condition is documented in your medical record
- You receive care from a Medicare-certified hospice agency
You do not need to be homebound to qualify for the Medicare hospice benefit. The benefit is a comprehensive set of services delivered by a team of providers. Most hospice services are provided in the home but inpatient care is covered under specific circumstances.
The hospice benefit is always covered under Original Medicare. If you have a Medicare Advantage plan and elect hospice, your hospice care will be paid for by Original Medicare.
Medicare beneficiaries who experience heart failure are now eligible for new benefits. Previously, Medicare only covered 36 rehab sessions for those who had a heart attack, bypass surgery or episodes of chest discomfort resulting from exertion, known as stable angina. Medicare recently extended cardiac rehab coverage to beneficiaries who have procedures like heart valve replacement, stenting or a heart transplant. According to CMS, two million Medicare beneficiaries are now eligible for this expanded coverage.