Washington Watch
Dying patients may find it more difficult to get certain medications under new rules Medicare has recently put in place. Meanwhile, another set of rules could make it easier for seniors to get Medicare to pay for home health care services.
Medicare has recently issued different sets of rules for payments involving hospice care and home health care services, as a result of a lawsuit settlement. But both of the rules changes are complicated and confusing and seniors may need some help in working their way through the changes.
In an effort to crack down on billing fraud problems, Medicare wants the federal government to stop paying millions of dollars to hospice organizations and drug insurance plans for the same prescriptions for seniors.
But the change has senior advocates worried that it could hurt the elderly who are dealing with hospice. The new measures direct insurers not to pay for any prescriptions for hospice patients until they get confirmation from Medicare that the drugs are not covered instead by the hospice provider. Requiring this additional authorization, Medicare officials say, will “prevent duplicate payments for drugs covered under the hospice benefit.
In general, medicines for Medicare patients getting hospice care are paid in two ways. Drugs related to comfort care and palliative care are supposed to be covered under the fixed-rate federal payments to the hospice. But drugs for diabetes, heart disease and other chronic conditions still used by these patients – but not directly related to their terminal illnesses – are instead covered by Medicare Part D prescription drug plans, with beneficiaries picking up roughly 25 percent of the bill. Those drugs are heavily subsidized by Medicare.
What prompted the change was a 2012 investigation that found Part D drug plans paid more than $33 million in 2009 that actually should have been covered by the hospice benefit for things like anti-nausea, laxative and anti-anxiety drugs. The investigation also found that drugs used to treat pulmonary problems and ALS, also known as Lou Gehrig’s disease, were paid by Part D instead of the hospice benefit. Beneficiaries paid almost $4 million in co-payments, according to the Health and Human Services Inspector General’s report.
The problem is that at the time they were prescribed, drug plans didn’t know if the drugs should have been covered by hospice groups. About 1.1 million Medicare beneficiaries received hospice care in 2009 and 437,121 filed prescriptions through their Medicare drug plan.
Now, under the new rules, Part D plans will initially reject any prescription from a hospice patient, instead of leaving it to insurers and hospice providers to identify the drugs they are responsible for. The patient or doctor, with the hospice provider’s agreement, will have to explain to the insurer why the drug is not related to end-of-life care.
The insurer can deny coverage for a number of reasons, including if the doctor or hospice didn’t sufficiently explain why the drug was unrelated to the terminal illness, Medicare officials told hospice organizations and insurers. Medicare officials say that in the past, the government’s guidance was “ambiguous” and provided no “objective criteria” in determining which way to cover the medications.
So, in other words, in an effort to crack down on complicated billing issues, Medicare is making it more difficult to get your meds if you are in hospice care, and therefore, nearing death.
Not surprisingly, while the plan just went into effect, it’s already causing some hospice patients or their families to leave their pharmacies without their medications.
“We had a couple of patients who went in to get their cardiac medications and were denied,” Susan Strauss, a registered nurse and chief compliance officer at Hope Health Inc., in Hyannis, Mass., which provides hospice care for 300 patients, told Kaiser Health News recently.
“Denying people cardiac meds – or the medication they need to breathe easier – that they have had for 30 years and are unrelated to their hospice diagnosis is causing them more pain, more anxiety and puts them at greater risk for more emergency room visits and hospitalizations,” said Strauss. You can be certain that the Massachusetts hospice care facility is far from the only place where meds are being denied.
If the Part D plan refused to cover a prescription, hospice patients or their authorized representatives will need to get their doctor’s help and request an expedited appeal from Medicare in order to improve their chances of getting the meds.
If a doctor says the patient’s health is in immediate jeopardy, a decision is supposed to be made within 24 hours and an appeals process is also available. For more details on this and other options, look at http://www.medicaladvocacy.org (and search for hospice) (for website version http://www.medicareadvocacy.org/hospice-and-access-to-medications-new-cms-guidance/.
Home health care coverage
Meanwhile, a 2012 lawsuit settlement has given folks with Parkinson’s disease and other crippling illnesses that need expensive skilled nursing and therapy services the option of getting it in their homes and having the costs covered by Medicare. But this too will require some extra work on behalf of those who handle the bills for you and your family. Under the 2012 settlement of Jimmo v. Sebelius, the U.S. Department of Health and Human Services agreed to relax Medicare’s requirements for coverage of skilled nursing and therapy services in institutional or home care settings.
Prior to the settlement, Medicare’s policy was to cover skilled nursing care only when patients had demonstrated medical potential to improve. Starting this year, the key criterion for coverage is a demonstrated need for skilled care – even if the patient isn’t expected to improve. That means patients already enrolled in Medicare Part A (hospitalization) who need care to maintain their current condition but aren’t likely to improve now qualify for Medicare’s standard benefits.
That should be good news for people like Robert Klaiber, 78, who has a physical therapist visit weekly to his Cape Cod, Mass., home, to provide a special type of massage that helps alleviate his symptoms from Parkinson’s disease and which costs $500 or more a month. Klaiber’s wife, Diane, thought Medicare wouldn’t cover the costs, but under these new rules, they should. Robert Klaiber receives physical therapy for his Parkinson’s, which is covered by Medicare.
The federal agency regards the settlement of Jimmo v. Sebelius as requiring a clarification of existing policy, not as new rule making. Nonetheless, the effect is that new coverage has become available for seniors, if they can manage to get it.
But actually getting the coverage has been a big problem for Diane and she’s not going to be the only one struggling with this. She now finds herself embroiled in a coverage dispute with Robert’s healthcare provider that underscores the rough start for this set of new Medicare rules.
Medicare recently published new rules spelling out the Jimmo v. Sebelius lawsuit rules changes, and an education campaign aimed at healthcare providers began in January. Diane has repeatedly talked with the nurse from Robert’s home healthcare provider, to no avail. The problem seems to be no one knows about the rules change.
Similar situations have led to a lawsuit being filed by Center for Medicare Advocacy and
Vermont Legal Aid, on behalf of four Medicare patients, and several national patients’ rights groups, including the Parkinson’s Action Network and the National Multiple Sclerosis Society.
But in both of these rule makings, help is available if your health care provider doesn’t understand how to handle a Medicare claim under the new rules or you need free counseling by phone at the Center for Medicare Advocacy (http://www.medicareadvocacy.org/) and the Medicare Rights Center (http://www.medicarerights.org/) which also offers free counseling by phone (1-800-333-4114).
The Center for Medicare Advocacy has been fighting for seniors since the mid-1980s and helps them understand the intricacies of Medicare and get fair access to it. The 2012 settlement requires Medicare to communicate the changes to health care providers and insurance companies, but not beneficiaries – so many folks aren’t aware that help is available.
Many people think Medicare covers long-term support and services, but the benefits are actually very limited. Medicare does pay for a stay of up to 100 days in a nursing or rehabilitation home following a related hospital admission with a $152 daily co-pay after 20 days of care. Medicare also covers skilled home health care, things like physical therapy or nursing services, if a doctor certifies that the care is necessary.
Medicare Part A also covers up to 100 home visits following a hospital stay. For patients who need care in their homes, Part B covers care without a prior hospitalization with no limits on visits and no co-pays for services and a 20 percent co-pay for durable medical equipment.
But the 2012 Jimmo v. Sebelius lawsuit settlement means Medicare now covers patients who need ongoing skilled care that isn’t expected to lead to long-term improvement. This can make a meaningful difference for patients, where care not covered by insurance is usually about $4,500 a month or more. Many seniors have commercial long-term care insurance, which helps cover the cost of a full-time home caregiver, but doesn’t pay for home-based skilled care.
The new rules apply in cases where your doctor indicates that you (or a loved one) need skilled nursing care or therapy to maintain current health.
Who to contact for help
This is complicated, so if trying to get this on your own seems overwhelming or confusing, help is also available with Medicare claims from your state Health Insurance Assistance; contact the Center for Medicare Advocacy at http://www.MedicareAdvocacy.org for more details. The Medicare Rights Center, http://www.medicarerights.org, 1-800-333-4114, another senior advocacy rights group, provides counseling and guidance for Medicare beneficiaries as well.
Free one-on-one help with Medicare claims is also available from the State Health Insurance Assistance Programs (SHIP), a network of non-profit Medicare counseling services. To find the SHIP program in your state, this link should help – http://bit.ly/1iqKgeZ
The Alaska Medicare Information Office can be reached at 269-3680 in Anchorage, or toll-free statewide at 1-800-478-6065. Their website address is http://dhss.alaska.gov/dsds/Pages/medicare/.
Also contributing to this story are Kaiser Health News and Reuters.
