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The 411
October 12, 2006 • Volume 6, Issue 41One of the flaws in the design of the Part D benefit is that it puts the keys to obtaining drug coverage in the hands of the underpaid, undertrained operators answering the phones for the Part D plans.
Since the May 15 open enrollment deadline passed, these call center operators have become the gate keepers for signing up for a Part D plan. Too often they denied enrollment to people eligible to sign up after the deadline because they were never properly trained on who qualifies for a special enrollment period under the rules established by the Centers for Medicare & Medicaid Services (CMS). People eligible to join because they had just left jobs providing medical benefits, for example, have simply been turned away.
Plan call centers are also a crucial link in the exceptions and appeals process, which is often the only way people with Medicare can get the medicines they need if their Part D plan restricts or denies coverage. Too often the plans’ operators cannot, or will not, inform callers about their right to appeal, accurately explain how to do it and provide the right contact information. Without clear information, the appeals process breaks down for people in need of their medication.
Most people enrolled in a Medicare Part D plan will get their one chance to change plans for 2007 starting on November 15. Many will call the plan's 800 number to find out if their drugs are covered. If the experience of 2006 is a guide, many operators will neglect to inform callers that a “covered” drug is subject to restrictions that effectively negate coverage.
For people with Medicare trying to unlock the complexities of Part D it can be infuriating when these customer service representatives cannot provide a straight answer, a correct answer or, sometimes, any answer.
But it's not their fault.
A simple, straightforward prescription drug benefit provided directly by Medicare would not have people with Medicare confused about their enrollment choices and calling clueless customer service representatives in a futile search for explanations. With a comprehensive drug benefit under Medicare, a face-to-face conversation with a doctor, instead of a phone call to an anonymous operator, would determine what medicines are prescribed and covered.
But that is not how Part D works. The fault lies in the design of Part D, and the blame lies with its designers: the Bush administration and the U.S. Congress. They are the ones who should feel our fury on Election Day.
In the meantime, however, it is up to CMS to make sure all Part D plans properly train their customer service representatives so that they can help people with Medicare obtain the information they need. Plan call centers should provide timely, complete and accurate information about how their plan works, not the runaround.
Medical Record
“[I]t is important to realize how few people with Medicare used the plan comparison tools developed by Medicare or obtained advice from a trained counselor, relying instead on information from the plans themselves…As [Medicare Payment Advisory Committee (MedPAC)] researchers discovered, however, this reliance on information provided by plans was problematic. For example, many focus group participants reported difficulty finding out whether their medications were covered when calling individual plan customer service centers” (“Getting the Runaround: Problems Obtaining Accurate Information from Part D Plans,” California Health Advocates and Medicare Rights Center, October 2006).
“Our calls to 10 of the largest PDP [stand-alone prescription drug plan] sponsors’ call centers show that Medicare beneficiaries face challenges in obtaining the information needed to make informed choices about the PDP that best meets their needs. Call center CSRs [customer service representatives] are expected to provide answer to drug benefit questions and comparative information about their sponsors’ PDP offerings. Yet we received accurate and complete responses to only about one-third of our calls. In addition, responses to the same question varied widely, both across and within call centers. Sponsor call centers’ poor performance on our five questions raises questions about whether the information they provide will lead beneficiaries to choose a PDP that costs them more than expected or has coverage that is different than expected” (“Medicare Part D: Prescription Drug Plan Sponsor Call Center Responses Were Prompt, but Not Consistently Accurate and Complete,” Government Accountability Office, June 2006).
“Mrs. G is a 74 year old woman who tried repeatedly to obtain a ‘workable knowledge’ of her Medicare Advantage prescription drug plan. She called both the plan and several pharmacists over several weeks but they were ‘unable to explain’ what expenses will apply toward her out-of-pocket costs. Mrs. G wanted to find out if it would be best for her to use [a different] pharmacy, but when she called the plan, the representative would not provider her with any information about the costs of her prescriptions or guidance on using a pharmacy outside of her plan network” (“Getting the Runaround: Problems Obtaining Accurate Information from Part D Plans,” California Health Advocates and Medicare Rights Center, October 2006).
***** The Medicare Rights Center (MRC) needs to hear about all the problems with the Medicare Part D benefit, whether they happen to you or someone in your community. With this information, we will be armed with the needed evidence to push for a Medicare-administered drug benefit.
Fast Relief: Part D Monitoring Project
Submit your story at www.medicarerights.org/partdstories.html
*****
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