50 Wishes for
Medicare’s Future

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Category:
Simplify Appeals

Require Part D plans to give the reason for a medication denial at the pharmacy counter

Knowing why a prescription drug is refused at the pharmacy counter is critical to helping beneficiaries determine their next steps—whether it is working with their physician to secure an alternative or appealing for coverage from their Part D plan. The federal government should require Part D plans to provide an individually tailored notice at the pharmacy counter when a medication is refused. The notice should explain why the prescription cannot be filled, for instance because it is off-formulary or because prior authorization is needed.

Require Part D coverage determinations at the pharmacy counter

After being refused a prescribed medication at the pharmacy, a beneficiary must formally request coverage from their Part D plan before the appeals process can even begin. In other words, a beneficiary must ask for a denial that she can then appeal. Being told no at the pharmacy doesn’t count as a formal denial. To ease beneficiary burdens and streamline the appeals process, the federal government should require Part D plans to make some types of coverage determinations at the pharmacy counter—eliminating a needless step in the appeals process for Medicare beneficiaries.

Allow appeals on the Part D specialty tier

When medically necessary, people with Part D have the right to request that their plan allow them to pay less for high-cost medications when a similar, lower-cost medicine is available on their plan’s formulary—this is known as a tiering exception. Unfairly, these same rights are not granted to beneficiaries whose prescription drugs are placed on the plan’s specialty tier, where cost-sharing can be exorbitant. Congress should pass legislation allowing Medicare beneficiaries the right to a tiering exception for specialty tier medications.

Add Part D to an integrated appeals process for Medicare-Medicaid managed care plans

In some states that are testing new care coordination models for dually eligible Medicare and Medicaid beneficiaries, the federal government is allowing the state and health plan to use an integrated appeals process. These innovative appeals models combine the best of the Medicare and Medicaid systems. But, this process is missing a critical element—prescription drug denials and appeals. The federal government should integrate Part D appeals as it continues to test how best to integrate care for those with Medicare and Medicaid coverage.

Improve Medicare Advantage (MA) and Part D denial notices

The most common call to the Medicare Rights national helpline comes from a beneficiary denied access to a health care service or prescription medication, and most of these calls are from people enrolled in an MA or Part D plan. All too often, beneficiaries struggle to interpret denial notices and remain unclear about their appeal rights. The federal government should require that MA and Part D plan denial notices include the right information (including clinical content), are available in languages other than English, and include content accessible to diverse health literacy levels.

Create an appeals process for beneficiaries in hospice care

Currently, beneficiaries receiving Medicare-covered hospice care do not have any recourse if they disagree with a determination made by their hospice provider, like the determination that a particular service is curative and non-covered. Congress should create a system for external review of provider decisions when the beneficiary disagrees with the hospice plan of care.