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Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

Advocates Seek MedPAC Review of Medicare Part D Appeals

October 16, 2014

Advocates Submit Letter Urging MedPAC to Recommend Improvements to the Part D Appeals Process

In a recent letter, the Medicare Rights Center and 22 other beneficiary and provider organizations urged the Medicare Payment Advisory Commission (MedPAC) to issue recommendations on how to improve the Part D appeals process. The letter references the availability of several new data sources, including plan-reported data on pharmacy transactions, coverage determinations and appeals recently made public for the first time by the Centers for Medicare & Medicaid Services (CMS).

Additionally, the letter references 2013 audit data for select Medicare Advantage (MA) and Part D plan sponsors made available by CMS. Alarmingly, CMS found that, of the plan sponsors audited, “89% issued denial letters to beneficiaries that either failed to include an adequate rationale [for the denial] …78% failed to demonstrate sufficient outreach to obtain additional information necessary to make an appropriate clinical decision, and 56% made inappropriate denials…”

The letter also notes that since the beginning of 2014, CMS has sanctioned 30 MA and Part D plan sponsor organizations. In 27 cases, these sanctions concerned coverage determinations, appeals and grievances. Finally, the letter cites data related to Part D appeals (known as reconsiderations) handled by an Independent Review Entity (IRE). The frequency with which some plan denials are reversed after the IRE review warrants additional scrutiny.

The letter concludes, “Considered all together, we believe recently released data on audits, sanctions and reconsiderations suggest significant room for improvement in the operation of Part D exceptions and appeals…we believe that MedPAC is well-suited to evaluate the Part D appeals system and to suggest specific recommendations to improve the Part D exceptions and appeals process.”

Click here to read the letter to MedPAC.

Click here to see Medicare Rights’ tips for appealing a Medicare health or drug plan’s denial.

KFF Brief Analyzes Medicare Advantage Plan Availability in 2015

Since the Affordable Care Act (ACA) was passed in 2010, the Medicare Advantage (MA) plan market has remained relatively stable, despite predictions that payment adjustments for MA plans may result in plans leaving the market and lead to a drop in enrollment. In fact, according to CMS, MA enrollment is on the rise, and will reach an all-time high for the fifth consecutive year.

According to a new Kaiser Family Foundation (KFF) issue brief examining the availability of MA plans nationwide, in 2015, the total number of available MA plans will be about the same as in 2014. In 2015, there will be 1,945 plans—a three percent decrease from 2014—and 84% of the plans offered in 2014 will be available in 2015. Additionally, in most states, the number of plans remains relatively stable. Ultimately, only about three percent of people with Medicare are currently in plans that will no longer be available in 2015.

The KFF brief complements a report released in July by the Medicare Rights Center. The Medicare Rights Center report, New York’s Medicare Marketplace—Update: Examining New York’s Medicare Advantage Plan Landscape after the Affordable Care Act, analyzed the MA plan landscape in New York State from 2011 through 2014 and found that payment adjustments to New York State MA plans have had minimal effect on the state’s MA market or on beneficiaries themselves.

Click here to read the KFF issue brief.

Click here to read Medicare Rights’ report.

Volume 5, Issue 40

Medicare Interactive logo

Medicare Reminder

If your Medicare Advantage plan is ending on December 31, 2014, you need to make timely decisions about your Medicare coverage. Keep in mind that most Medicare Advantage plans include Medicare health and prescription drug coverage, so you will need to think of about both types of coverage.

Below are steps to take regarding Medicare health and prescription drug coverage when your Medicare Advantage plan is ending.

1. If your Medicare Advantage plan is ending at the end of the calendar year, you should receive a letter from your plan by October 2, 2014 to tell you that your plan won’t be available next year. Make sure you keep this letter from you plan. You may need it later to prove you have the right to join other Medicare plans or to sign up for a Medigap plan as explained below.

2. Decide how you want to want to get your health and drug coverage next year. You can either select another Medicare Advantage plan or switch to Original Medicare to continue getting Medicare health benefits. If you need Medicare prescription drug coverage, most Medicare Advantage plans include drug coverage. If you change to Original Medicare, you will need to join a stand-alone Part D prescription drug plan to get Medicare drug coverage.

3. Make your plan selections before the end of 2014 to ensure you have the drug and health coverage you need on January 1, 2015.

Click here to read more about what to do if your plan is ending on Medicare Interactive.



Last week, the Department of Health and Human Services (HHS) announced that, in 2015, the standard Medicare Part B premium will remain $104.90 per month—the third consecutive year of premium stability. The Part B deductible will also remain the same at $147.

The announcement that Medicare premiums and deductibles are unchanged is welcome news for people with Medicare, many of whom already shoulder high health care costs on low, fixed incomes. Half of all people with Medicare live on annual incomes of $23,500 or less, and the average Medicare household spends 14% of household expenses toward health care costs, compared with only 5% among non-Medicare households.

Click here to read the HHS announcement.


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