Your Weekly Medicare Consumer Advocacy Update
Taking Our Message to Congress
Medicare Rights Testifies in Congress on Rule Proposing Changes to Medicare Advantage and Part D
This week, Joe Baker, President of the Medicare Rights Center, testified before the Subcommittee on Health of the U.S. House Committee on Energy and Commerce about recent changes to the Medicare Advantage and the Part D prescription drug program proposed by the Centers for Medicare & Medicaid Services (CMS).
In his testimony, Mr. Baker recognized the strides that CMS seeks to make in the areas of oversight, monitoring and transparency. He also emphasized that each of the proposed policies reflected in the rule should be evaluated on their own merits—as opposed to supporting or opposing the proposed rule as a whole.
The provisions of the rule that the Medicare Rights Center supports include those that would:
- Ensure meaningful differences between Part D plans
- Increase drug pricing transparency, fairness, and accuracy
- Enhance Medicare Advantage and Part D plan oversight
- Improve beneficiary notices detailing plan changes
“We strongly support CMS’ desire to ensure meaningful differences among Part D plans by further consolidating plan options,” said Mr. Baker. “On our national helpline, we observe that older adults and people with disabilities find choosing among a large number of Part D plans to be a dizzying experience. Most people with Medicare fail to reevaluate their coverage options on an annual basis, largely because there are too many options and too many variables to compare, even when they can save money or increase their coverage by switching plans.”
Mr. Baker’s testimony also expressed opposition to CMS’ proposed policy to scale back the protected drug classes in Medicare Part D, which would end open formulary access for the antidepressant, antipsychotic and immunosuppressant drug classes. The testimony asserts that CMS’ reliance on existing beneficiary protections, including the Part D appeals process, to preserve access to drugs that lose protected status is misplaced.
“Based on our experience counseling Medicare beneficiaries, we believe the protections that CMS refers to are insufficient—especially the Part D appeals process,” said Mr. Baker. “According to CMS, over half of plan-level denials are overturned after they are independently reviewed. This alarming rate of reversals raises serious questions about how well the appeals process can be counted upon to protect beneficiaries. More importantly, the appeals process must be streamlined so that people who are denied drugs can get a denial notice from their plan at the pharmacy counter.”
CMS also points to drug prices as a primary reason for scaling back the protected drug classes. Mr. Baker recognizes that these concerns are valid, but that CMS should not pursue policies that unduly restrict access in order to address the problem.
Mr. Baker concluded his testimony by saying, “To address concerns regarding drug pricing in Medicare, Congress should restore previously proposed Medicare drug rebates for beneficiaries dually eligible for both Medicare and Medicaid, which would save taxpayers over $140 billion over 10 years. These significant savings could be achieved without increasing beneficiary costs or restricting access.”
Dispute Over Proposed Medicare Advantage Rate Reductions
A recent Kaiser Health News article discussed the debate surrounding the proposed adjustments to federal funding rates paid to Medicare Advantage plans. The proposed rates for 2015 were recently released and included a 1.9 percent reduction in Medicare Advantage reimbursement rates. Medicare Advantage plans and advocates have differing opinions about whether this proposed adjustment is positive or negative.
According to the article, many Medicare Advantage plans are arguing that this adjustment will translate into increased costs for beneficiaries. Some plans argue that the additional rate adjustments—including those made by budget sequestration, the Affordable Care Act (ACA) tax on health insurance premiums, and the ACA reduction in plan subsidies—result in a larger decrease in payment than the 1.9 percent rate reduction suggests. Initially, there was a proposed 2.2 percent rate cut for 2014, but this was revised to a 3.3 percent increase after a campaign by insurers. Plans argue that, combined with the other factors, the resulting 3.3 percent increase actually translated to a more than 6 percent cut in payment rates for 2014.
However, advocates point out that these same predictions have been made in the past, but simply have not proven true. Medicare Rights Center President Joe Baker stated, “We have really overall had a rather calm year so the ‘sky is falling’ predictions from the health insurance industry did not come true.” In fact, an increasing number of Medicare beneficiaries have opted to enroll in Medicare Advantage plans. This year, Medicare Advantage plan enrollment is up nearly 9 percent. It appears that this debate will continue, since the ACA will continue to reduce payments to Medicare Advantage plans in the coming years until they are in line with the cost of Original Medicare.
Volume 5, Issue 8
If you were denied coverage for a prescription drug, you should ask your plan to reconsider its decision by filing an appeal. Your appeal process will be the same whether you have a stand-alone Part D prescription drug plan or a Medicare Advantage plan that includes your Part D prescription drug coverage.
If your pharmacist tells you that your plan will not pay for your prescription drug, you should call your plan to find out the reason it is not covering your drug. Then, you should talk to your prescribing physician about your options. If switching to another drug is not an option, you should file an exception request – a formal coverage request – with your plan. Call your plan to learn how to file an exception request. Make sure you get a letter of support from your doctor and include that with your request.
Your plan should issue a decision within 72 hours. File an expedite request if you need your drug right away, and your plan should issue a decision within 24 hours. If your request is approved, your drug will be covered. If it is denied, you should follow the directions on the written denial you receive to appeal.
Earlier this month, the Medicare Rights Center launched Medicare Rights University (MRU), an online learning tool designed to empower professionals to better help their own clients, patients, employees, retirees, and others navigate a multitude of Medicare questions. Find out what MRU has to offer today, and take our free Medicare assessment to test your Medicare knowledge with a short quiz. After the quiz, you will receive a recommendation on where to begin your Medicare learning.