Compliance Still an Issue for Medicare Advantage and Prescription Drug Plans
According to a recent memorandum released by the Centers for Medicare & Medicaid Services (CMS), some Part C Medicare private health plans, also known as Medicare Advantage plans, and Part D Medicare Prescription Drug Plans are facing compliance issues. The memo presents the findings of 11 program audits conducted by CMS in 2011 to monitor and improve plan compliance under the Part C and D programs.
In its memo, CMS notes that sponsors did not understand transition and formulary requirements, and often delegated such responsibilities to their Pharmacy Benefit Managers (PBMs). However, plans did not engage in proper oversight of the activities of their PBMs. CMS also found that several plan sponsors were not compliant with the requirements for Part D coverage determination, appeals and grievance processes. Specifically, the audits found that sponsors misclassified coverage determinations as grievances, did not properly track coverage and appeals requests, and did not use due diligence in resolving coverage determinations, redeterminations and grievances. The memo also cites a lack of compliance with CMS requirements for outbound enrollment verification calls and the complaints process, including a failure to execute enrollment cancellation requests and a failure to track and provide oversight of outbound enrollment verification calls.
In an effort to help plans comply with requirements under the Part C and D programs, CMS also includes best practices. For example, CMS recommends that plans engage in better oversight of PBMs, and examine both paid and rejected Part D transition fill claims to ensure that plans provide transition fills to their members appropriately. In order to prevent misclassification of requests, CMS also recommends that plans provide better training to their customer service representatives around the coverage determination, appeals and grievance processes. In addition, CMS recommends that the content of denial letters include the specific reason for the denial of coverage, as well as a clear explanation of the additional information and documentation needed to obtain coverage. The Medicare Rights Center regularly provides comments to CMS that reiterate the importance of including such accurate and detailed information in denial and appeals notices. Beneficiaries are often unable to pursue an appeal successfully because they have not been adequately informed by their plans of what to include in an appeal.
Read the CMS memo, “2011 Program Audit Findings and Best Practices.”
Center for Medicare and Medicaid Innovation Looks to the Past, Present, and Future
Today, the Center for Medicare and Medicaid Innovation (CMMI), part of the Centers for Medicare & Medicaid Services (CMS), released a report titled, “One Year of Innovation, Taking Action to Improve Care and Reduce Costs.” The report highlights CMMI’s work over the past year. CMMI was created by the Affordable Care Act (ACA) with the mission of identifying, testing and spreading delivery and payment system reforms and models, all in an effort to improve the quality of care people receive, while also reducing costs. During its first year of operation, CMMI initiated 16 programs.
Programs highlighted in the report include the Partnership for Patients, a public-private partnership that includes consumers, employers, and health care providers, such as hospitals and physicians. Members of the Partnership for Patients have pledged to reduce preventable hospital-acquired conditions by 40 percent and hospital readmissions within 30 days of discharge by 20 percent over the next three years. CMMI’s report also discusses initiatives that target dual-eligibles, or individuals who have both Medicare and Medicaid. For example, CMMI works closely with the Medicare-Medicaid Coordination Office to test new payment and delivery system models, in an effort to improve the health status of dually eligible beneficiaries, while also curbing spending.
The report comes shortly after the release of a Congressional Budget Office (CBO) analysis of CMS demonstration projects related to disease management, care coordination and value-based purchasing under the Medicare program. The CBO report states that while certain demonstrations indicated modest success, others were ineffective. While the report states that most demonstrations did not result in significant savings to the Medicare program, it recommends various ways to improve future demonstration projects to generate savings and improve quality of care. Dr. Richard Gilfillan, director of the CMMI, issued a response to the CBO report, stating that CMMI has been and will continue implementing many of the CBO’s recommendations, including focusing on data collection, care transitions and interventions for high-risk patients.
Read CMMI’s report, “One Year of Innovation, Taking Action to Improve Care and Reduce Costs.”
Read the CBO’s report, “Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination and Value-Based Payment.”
Read CMMI’s response to the CBO’s report, “New CBO Report Supports Innovation Center’s Approach to Improving Care.”
Medicare does not include a comprehensive long-term care benefit. Medicare covers up to 100 days of care in a Medicare-certified skilled nursing facility after you have spent three days in the hospital, and as long as you need skilled care. In some cases, Medicare will cover home health care if you receive services through a Medicare-certified home health agency, require skilled care and meet other criteria. Medicare will also pay for hospice care for people who are terminally ill.
If you have a chronic illness or disability and need long-term supportive services, you will probably need to find resources other than Medicare to help pay for your care. For instance:
- Medicaid may help pay for home health care, nursing home and other long-term care services if you have limited income and meet other eligibility requirements.
- The Department of Veterans Affairs offers long-term care services to some eligible veterans through different national programs and facilities.
- The Program of All-Inclusive Care for the Elderly, a government program available in certain states to people with Medicare and Medicaid, provides medical, social and rehabilitative services to people who qualify.
- Long-term care insurance from private insurance companies covers some of the costs of long-term care.
Learn more about how to get help paying for long-term care needs at www.medicareinteractive.org.
Last week, the Columbia Journalism Review published a conversation with Henry Aaron, a senior fellow at the Brookings Institute, in which Aaron explains the ideas behind different proposals to change Medicare, including premium support, or voucher, programs. In the conversation, he also explores the implications of implementing such policies for private insurance companies, the federal government and Medicare beneficiaries.
Read the conversation, “Medicare Vouchers Explained.”