Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

CMS Proposes Improvements to Medicare Advantage and Part D

February 26, 2015

Medicare Rights Applauds Proposed Changes to Medicare Advantage and Part D Appeals

This week, the Medicare Rights Center released a statement expressing support for the positive steps proposed by CMS to address long-standing issues with the Medicare Advantage (MA) and Part D appeals system. In CMS’ advance notice of changes to MA and Part D in 2016, the agency proposes to improve beneficiary access to care by improving denial notices sent to people with MA and Part D. They also clarify the expectation that plans seek medical information from a prescriber to support a prescription drug request. Medicare Rights expects this clarification will help ensure uninterrupted access to needed medicines and reduce existing burdens on beneficiaries to produce such information.

Specifically, Medicare Rights applauds CMS “…for taking seriously the results of recent audits showing deficits in denial notices and for taking concrete steps to improve those essential documents.” The statement also thanks CMS for addressing Medicare Rights’ concerns about “…the lack of personalized, actionable information pertaining to denials of coverage for prescriptions or other clinical or benefit changes at the pharmacy counter.”

The statement concludes, “We are encouraged by the proposed improvements and look forward to working with our partners and CMS to streamline the appeals process for beneficiaries and to reduce known barriers to accessing needed health care services and prescription drugs.” Medicare Rights will provide more detailed comment on the advance call letter, expressing strong support for these provisions.

Read more in the advance notice of proposed changes to MA and Part D for 2016 (starts at the bottom of pg. 76).

Read Medicare Rights’ statement.

CMS Proposes Increased Oversight of Medicare Advantage Plan Network List Accuracy

In the recently released advance notice of the call letter for changes to Medicare Advantage (MA) and Part D in 2016, the Center for Medicare & Medicaid Services (CMS) addresses a “wide range” of problems with online and print provider directories (the lists of doctors and facilities that are in-network for a given plan). These resources, which greatly influence a patient’s choice of provider, are supposed to provide up-to-date information about which providers participate in the plan.

For beneficiaries, Medicare Rights observes that incorrect or outdated directories can result in higher out-of-pocket costs or outright denials of coverage. Medicare Rights also hears from beneficiaries who make plan selections based on a plan’s network directory only to find that their preferred choice is not accepting new patients.

In response to these problems, CMS proposes new rules about what plans should include in their provider directories—particularly information about whether providers are accepting new patients and up-to-date contact information. Additionally, CMS clarifies that provider directories must be updated at least four times a year. To enforce these new rules, CMS secured additional contractor funding to review online directories and plans to increase audits.  If plans are found to have inadequate or outdated lists and/or networks, they can be fined or subject to sanctions that prohibit them from enrolling new members.

Moreover, CMS is exploring the possibility of requiring uniform digital provider lists by 2017. Medicare Rights will express strong support for these provisions in its comments on the advance call letter. At the same time, Medicare Rights continues to urge CMS to create mechanisms for comparing MA plan provider networks through updates to the Plan Finder tool.

Read more in the advance notice of proposed changes to MA and Part D for 2016 (pg. 134).

Volume 6, Issue 7

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Medicare Reminder

If your Medicare Advantage plan (Medicare private health plan) or Medicare prescription drug plan makes any changes during the plan year they must notify you.

Network provider changes:

Most Medicare Advantage plans have networks of doctors, hospitals and other providers. You typically pay less if you see providers that are in your plan’s network. Most people can only change their plan once a year during the Fall Open Enrollment Period, but providers can leave a plan’s network at anytime.

When a provider is leaving a plan’s network, the plan must try and send all the plan members who use that provider a written notice at least 30 days before the provider leaves the network.

Mid-year formulary changes:

If your drug plan makes changes to its formulary during the year, you have certain rights depending on why the plan made the change.

If a drug is declared unsafe by the Food and Drug Administration (FDA) a plan can remove the drug from their formulary at anytime. When a drug is removed by the FDA the plan must notify anyone who might be affected.

If the plan is making maintenance changes, they must give you 60 days notice or provide you with a 60 day transition fill. Maintenance changes include covering a generic drug instead of a brand-name drug or adding quantity limits for drugs that the FDA adds warnings to, and making formulary changes based on clinical best practices and safety concerns.

If your plan is making non-maintenance changes, which is any other change, and you are already taking the drug you must be allowed to continuing taking that drug for the rest of the year as long as it is medically necessary. Your plan must also send you a notification in the mail stating that the drug is no longer on their formulary but it will be covered for you for the rest of the year.

When a plan makes any of these changes they are required to update both the online and print version of their formulary. If you are going to be affected by any of the changes to your plan’s formulary, they must send you a copy of the updated formulary in the mail.

Learn more at


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Earlier this month, the Medicare Rights Center finalized a Medicare Rights University (MRU) module focused on providing professionals with the tools they need to understand hospital transitions. The module explores Medicare’s hospital discharge rules and regulations, recommendations for easing your patients’ transitions, and how Medicare pays for various aspects of inpatient and outpatient care.

Registering for this MRU module is quick and easy. Simply visit and click the “Register” button in the top left-hand corner. Additionally, if you are looking for materials for your patients, or are a consumer seeking discharge planning information, we encourage you to explore Medicare discharge planning content on our proven resource, Medicare Interactive.


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