Your Weekly Medicare Consumer Advocacy Update
House Passes Medicare ‘Doc Fix’
House of Representatives Votes to Fix Medicare Payments for Doctors
Today the House passed a bill, the Medicare Access and CHIP Reauthorization Act of 2015 (H.R.2), to repeal the formula for physician payment under Medicare and extend the Children’s Health Insurance Program (CHIP) for two years. Congress has acted 17 times to temporarily prevent the formula, called the Sustainable Growth Rate (SGR), from going into effect. H.R.2 would replace the SGR with alternative, value-driven payment strategies. The bill also permanently funds the Qualified Individual (QI) program that helps low-income Medicare beneficiaries afford Part B premiums.
Medicare Rights supports this bipartisan effort to repeal and replace the SGR. Yet, Medicare Rights and other beneficiary advocates are concerned that the current replacement proposal asks beneficiaries to shoulder too much of the cost of this legislation—$30 billion in higher costs would be shifted to some beneficiaries. Reflecting that concern, Medicare Rights wrote a letter to House Speaker John Boehner and Democratic Leader Nancy Pelosi, expressing the need for additional improvements for low-income beneficiaries as the Senate takes up the legislation.
Medicare Rights Asks CMS to Improve the Part D Appeals Process
Every year, Medicare Rights helps thousands of individuals navigate the complicated Medicare Part D appeals process, which allows beneficiaries to challenge a prescription drug plan’s coverage decision. Because the process is the equivalent of a nonsensical maze, it leaves beneficiaries confused, frustrated, and unable to adhere to prescribed treatment plans.
The most recent audit conducted by the Center for Medicare and Medicaid Services (CMS) of Part D and Medicare Advantage (MA) plan sponsors showed that:
- 89% issued denial letters to beneficiaries that either failed to include an adequate rationale or contained incorrect information
- 78% failed to demonstrate sufficient outreach to obtain additional information necessary to make an appropriate clinical decision
- 56% made inappropriate denials when processing coverage determinations
- 61% were shown to apply unapproved quantity limits
- 50% were shown to apply unapproved utilization management practices
The Medicare Rights Center is asking CMS to immediately implement reforms to help people with Medicare better navigate Part D denials and appeals.
Volume 6, Issue 11
The coverage gap, also known as the doughnut hole, is a period of time during your Part D prescription drug coverage when the amount you pay for your drugs suddenly increases. The coverage gap starts when your total drug costs—including what you and your plan have paid for drugs—reaches $2,960 in 2015.
As a result of the Affordable Care Act, you get discounts to help you pay for your drugs during the coverage gap. In 2015, there is a 55 percent discount on brand-name drugs and a 35 percent discount on generic drugs while you are in the coverage gap. These discounts will gradually increase each year until 2020, when you will typically pay no more than 25 percent of the cost of your drug.
In 2015, once you have paid $4,700 out-of-pocket, you reach catastrophic coverage. During catastrophic coverage, your costs will be significantly less.
Five years ago this week, the Affordable Care Act (ACA) was passed into law, bringing real benefits to the tens of millions of Americans who have Medicare. Older adults and people with disabilities are now receiving low-to-no cost preventive services as well as more affordable prescription drugs in the coverage gap.
In a statement, Medicare Rights Center President Joe Baker said, “The ACA tackles the systemic causes of rising costs in the Medicare program, and so far the results continue to be promising. Most importantly, the ACA demonstrates that the federal government can contain costs without shifting even higher health care costs to beneficiaries, all while improving Medicare benefits. Continued implementation of the ACA is essential to preserving and strengthening Medicare for today’s and future beneficiaries.”