Clinical Geriatrics

As is too often the case, federal legislation has set up a system that did not fully take into account the unique environment that exists in nursing facilities. Medicare Part D is a prime example. In addition to difficulties imposed by the unique and already heavily regulated environment of nursing facilities, these regulations are now in conflict with the new Part D federal legislation.

The basis for this conflict is Medicare Conditions of Participation that requires skilled nursing facilities (SNFs) to provide all of the care and services that are medically necessary to their residents in a timely manner. As a result, SNFs have a responsibility to ensure that each resident receives every medication ordered in a timely manner. This was not a problem pre-Medicare Part D, when most prescriptions were being covered without restriction by state Medicaid programs. Post-Medicare Part D, however, a new entity was added that oftentimes restricts timely delivery of medications to residents.

The mechanisms most likely leading to restriction involve nonformulary medication, off-label use, quantity limits, and excluded medications. To best illustrate this problem, we will walk through several cases that SNFs are likely to encounter, especially now that the special transition period has ended. This period, which ended March 31, forced prescription drug plans (PDPs) to continue to provide coverage for medications that a member had been receiving prior to joining their plan. For most nursing home residents, this meant that medications they had access to through Medicaid were continued through March 31, but after that date, it required going through the appeals and exceptions process, changing medications, or changing plans to get access.

The dually eligible—those with Medicare and Medicaid—and those living in long-term care (LTC) facilities have the ability to utilize a Special Enrollment Period (SEP). Through the SEP, LTC residents who find themselves in PDPs that do not provide the medications they need can change plans. The new plan that they choose would become effective the first day of the month following their enrollment, with the previous plan continuing coverage until that time. In some cases, it may be easier for nursing home residents to change plans rather than go through the appeals and exceptions process. If the PDP does not provide coverage for a medication ordered by a nursing home physician, the nursing facility would become responsible for providing the medication, as is the situation in the cases presented below.

Each of the following cases points out the financial liability a nursing facility will find itself under if it is not taking a proactive stand in assuring that residents are enrolled in the PDP that offers access to their needed medications. In addition, a nursing facility’s prescribers need to write orders within the scope of the PDP, or be prepared to argue through the appeals and exceptions process to gain access to the needed medication. Here are four cases in which the nursing facility would find itself financially liable for ensuring access to ordered medications:

Case 1:
NONFORMULARY MEDICATIONS
Dr. Smith has ordered a medication for Mr. Johnson, but his PDP does not cover it. The physician is unwilling to change the order to what the PDP considers the appropriate medications because Mr. Johnson has tried and failed the medications available through the PDP. Mr. Johnson is dually eligible, so he does not have the ability to pay for the medication. As a result, the facility may need to pay for the medication to ensure that it is available in a timely manner.

Case 2:
OFF-LABEL USE
Ms. Williams has moderate-to-severe dementia that is being controlled with two agents. Her PDP requires Mini-Mental State Examinations. Because both medications are not indicated given her level of dementia, the PDP refuses coverage of one of the antidementia agents.