CMS/RelayHealth Hospice Part D Pilot Project

Under the Medicare hospice benefit, coverage for services, drugs and items related to the terminal illness and related conditions are covered under the bundled Medicare Part A benefit. CMS is concerned about hospice related prescription drugs being paid by the Part D benefit instead of the Hospice benefit.

In the 2022 Fiscal Year Hospice Wage Index and Quality Reporting proposed rule, published in April 2021, CMS reported that in 2019, the amount of Part D spending, while patients were on hospice care, reached almost $500 million ($498,913,448). A concern identified by CMS Part D is that the hospice election is not reaching the Medicare Part D plan timely. Due to this delay, the Medicare Part D plan does not know that an enrollee has elected their hospice benefit and is continuing to pay for medications that should be paid by the hospice. A study by one Medicare Part D plan discovered that the median time from submission of the Notice of Election (NOE) by the hospice to the Part D plan was 16 days, and one notification took 65 days.

CMS Part D has contracted with RelayHealth to design a hospice election notification system to provide the notice of hospice election to the Medicare Part D plans more timely, allowing the Medicare Part D plan to reject medications when a drug may be related to the hospice patient’s condition. A high-level summary of the pilot notification process is below:

A high-level summary of the notification process for Hospice

Importance of this project: The Health and Human Services Office of Inspector General (OIG) issued two reports pertaining to the amount of spending by Medicare Part D after the hospice election was chosen. The OIG issued strong recommendations to CMS to suggest that CMS Part D develop solutions to the current problem. Without action to resolve this situation, increased scrutiny of hospices with beneficiaries who also have Medicare Part D plans is likely to occur. This project is designed to address the concerns of the OIG.

Pilot Program: RelayHealth (Medicare Part D Transaction Facilitator) in conjunction with NCPDP and hospice industry participants have developed a process to act as a transaction facilitator and communicate the hospice NOE information to the Medicare Part D plans directly. With the help of National Hospice and Palliative Care Organization (NHPCO) and the National Association for Home Care & Hospice (NAHC), hospice electronic medical records (EMR) vendors and their clearinghouses are participating in this pilot program. This pilot program will transmit hospice election information via the electronic 837i standard to RelayHealth. RelayHealth will then transmit these elections via the NCPDP information reporting transaction standard (Nx) to the Medicare Part D plans. The goal of the program is to significantly reduce the time elapsed between when the NOE is submitted and when the Medicare Part D plan receives the NOE.

The EMR pilot participants are Axxess, MatrixCare and Netsmart.

The Clearinghouse participants are Axxess and Waystar.