Medicare Part D Issues: Timely Services and Medication Coverage Issues
PDF Version of BQA 06-004
(PDF
34 KB)
Date: June 8, 2006 -- DDES-BQA 06-004
To: Nursing Homes
NH 03, Adult Day Care Centers
ADC 02, Adult Family Homes
AFH 02, Community Based Residential Facilities
CBRF 02, Residential Care Apartment Complexes
RCAC 02
From: Doug Englebert, Pharmacy Practice Consultant
Via: Jan Eakins, PRQI
Background--Timely Services
The enactment of the Medicare Modernization Act created new
requirements under Medicare Part D. These requirements may have affected
the timely availability of medication to treat specific conditions.
Health care providers have the responsibility to meet residents' needs
for health and comfort. Timely services are a component of prompt and
adequate pharmacy services requirements. The intent of these requirements
is to ensure that medications ordered for residents are provided and
administered in a timely manner to optimize care and prevent harm to
residents. Surveyors evaluate timely services by determining if failure to
provide a medication timely, or find other acceptable treatment, causes
resident discomfort or endangers resident safety. If there is resident
discomfort or endangerment then the requirement to provide timely services
is not met.
In some cases, facilities have adopted policies requiring medications
to be delivered from the pharmacy within certain time frames in an attempt
to meet the timely services requirement. Since the requirement for timely
services is not based on time frames, policies requiring time frames do
not ensure the requirements will be met.
In July 2004, the Bureau of Quality Assurance (BQA) issued memo
04-018 addressing timely services related to medications. This memo
was initiated as Medicaid was implementing more comprehensive prior
authorization programs and preferred medication lists. These changes
required providers to seek changes in medications, or submit information
for prior authorization, all of which may have delayed medication
delivery. The purpose of BQA memo 04-018 was to clarify the definition of
timely services, and to inform facilities that if medications are not
delivered based on a specific time frame, it does not automatically mean
services are not provided timely. This allows a facility to have
medications delivered on variable time frames to meet the needs of
residents.
Timely Services
Since BQA memo 04-018 was issued, the pharmacy environment has changed
as a result of Medicare Part D. There has been an increase in the
complexity and volume of required medication changes and prior
authorizations, and the creation of preferred medication lists. These
changes increase the chance that a medication delivery may be delayed. I
emphasize again that timely services are not defined by a specific time
frame. Timely services are based on assuring residents do not experience
discomfort or are not endangered.
As delays of medication delivery occur, a key component to assuring
that a resident's needs are met in a timely basis is communication among
the facility, the pharmacy and the physician. Facilities that experience
delays in medication delivery must continue to meet the resident's needs.
That may mean communicating with the physician and pharmacist to determine
that a delay in medication delivery will not endanger or cause discomfort
to the resident, switching the resident to another medication, or
implementing a different care approach. Implementing delivery time
requirements will not ensure that a resident's needs are met. Therefore,
facilities should not simply rely on time requirements, but instead,
ensure that there is clear communication and follow-up with the physician
and pharmacist to assure that residents' needs are being met.
The Centers for Medicare and Medicaid recently released some materials
related to transition supplies to assist providers after the extended
transition supply ended March 31, 2006. These materials can be accessed
at:
CMS Fact Sheet: http://www.cms.hhs.gov/apps/media/?media=fact
(exit DHS)
CMS What If Doc "Getting Drugs After Your Transition": http://www.medicare.gov/WhatIfTransition_option2.pdf
(exit DHS; PDF 45 KB)
Medication Coverage Issues
1) Leave of Absence Medications: When residents leave facilities for a
vacation, some Part D plans will not pay for a leave-of-absence supply of
medications. In these cases, if the appropriately labeled medications have
remained in the package received from the pharmacy, the supply of
medication can be provided to the resident to take on leave. Facilities
should consult with the resident's pharmacy to determine if a
leave-of-absence supply is available.
2) New Admission: When a resident is newly admitted, facilities
typically review physician orders for needed medications and request a new
supply from a pharmacy. If a resident had the prescriptions recently
filled at the same or another pharmacy, the new supply of the same
medications may not be authorized by the Part D plan. Often the pharmacy
will receive a message from the Part D plan that the medication is being
refilled too soon. Currently, there are no regulations that prohibit a
facility from administering the supply of medications left over from the
facility or home where the resident previously resided. However,
facilities will need to assure that the medications came from a licensed
pharmacy and confirm the identity of each medication prior to
administering the medications.
3) Resident Refusal: A resident sometimes chooses a Part D plan that
does not cover some medications the resident needs, and the resident
refuses to change plans. In other instances, a resident refuses to meet
co-payments or deductibles as required, or a resident simply refuses a
medication. Residents have the right to make these decisions. However,
these decisions create risks for residents, and the facility should
explain those risks to them. It may be necessary to enlist the assistance
of the resident's family, physician, the facility's medical director,
social worker, pharmacy consultant, or others, as appropriate, to
determine the reasons for refusal, and to reduce the potential for
negative outcomes to the resident. Alternative treatment options may be
considered.
4) Appeals: Each Part D plan is required to have a coverage
determination exemption, as well has an appeal process to address
situations when a resident's medications are not covered. Residents have
the right to use these processes. Facilities may need to assist residents
with these processes. Each plan should have provided this information to
residents. If that information is not available, facilities can call
1-800-MEDICARE to obtain it.
If you have questions about the contents of this memo, please call Doug
Englebert, Pharmacy Practice Consultant at (608) 266-5388 or e-mail him at
engleda@DHS.state.wi.us.
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