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Denials and Appeals

Largely driven by prior authorization, MA and Part D coverage denials leave beneficiaries with only bad options: paying out-of-pocket, going without, or getting embroiled in a daunting and deeply flawed appeals process. Each path can lead to delayed care, abandoned therapies, worse health, and higher costs. Particularly egregious are improper coverage denials, which force people to make this choice unnecessarily. Changes are long overdue. Harmful denials must be curbed, and the appeals systems must be reformed to function as a safety valve—rather than as an inadequate substitute for sound plan decisions and robust federal oversight.

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Interoperability and Prior Authorization Proposed Rule

March 13, 2023

The Medicare Rights Center (Medicare Rights) appreciates this opportunity to comment on the Advancing Interoperability and Improving Prior Authorization Processes proposed rule.

Prior authorization is creating an ever-increasing burden on patients. We support many of the Centers for Medicare & Medicaid Services (CMS) provisions in this proposed rule that would reduce this burden by improving processes, timelines, access to information, and communication.

Read More »

Medicare Part D Appeals Problems and Options to Correct Them

March 1, 2023

The Medicare Part D appeals process is an essential safety valve, allowing access to needed prescription medications—such as those that are not on the plan’s formulary, or are subject to high cost sharing, when formulary or lower cost alternatives are not appropriate. However, Part D enrollees often struggle to successfully navigate this overly complex, multi-step, process, and it can also prove burdensome for pharmacists, plans, and prescribing physicians. This can result in delayed access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs for the patient and the Medicare program.

Read More »

Statement for the Record “Negotiating a Better Deal: Legislation to Lower the Cost of Prescription Drugs”

May 4, 2021

Immediate action is needed to transform the nation’s drug pricing system in ways that will lower prices, strengthen Medicare, and promote the well-being of those who rely on its coverage. H.R. 3 would significantly advance these goals, in part by authorizing Medicare to negotiate prices for certain drugs; imposing inflationary rebates; and restructuring Part D to cap beneficiary out-of-pocket costs at $2,000 per year, reduce the federal government’s liability, and better align pricing incentives.

Read More »

Interoperability and Prior Authorization Proposed Rule

March 13, 2023

The Medicare Rights Center (Medicare Rights) appreciates this opportunity to comment on the Advancing Interoperability and Improving Prior Authorization Processes proposed rule.

Prior authorization is creating an ever-increasing burden on patients. We support many of the Centers for Medicare & Medicaid Services (CMS) provisions in this proposed rule that would reduce this burden by improving processes, timelines, access to information, and communication.

Medicare Part D Appeals Problems and Options to Correct Them

March 1, 2023

The Medicare Part D appeals process is an essential safety valve, allowing access to needed prescription medications—such as those that are not on the plan’s formulary, or are subject to high cost sharing, when formulary or lower cost alternatives are not appropriate. However, Part D enrollees often struggle to successfully navigate this overly complex, multi-step, process, and it can also prove burdensome for pharmacists, plans, and prescribing physicians. This can result in delayed access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs for the patient and the Medicare program.

Statement for the Record “Negotiating a Better Deal: Legislation to Lower the Cost of Prescription Drugs”

May 4, 2021

Immediate action is needed to transform the nation’s drug pricing system in ways that will lower prices, strengthen Medicare, and promote the well-being of those who rely on its coverage. H.R. 3 would significantly advance these goals, in part by authorizing Medicare to negotiate prices for certain drugs; imposing inflationary rebates; and restructuring Part D to cap beneficiary out-of-pocket costs at $2,000 per year, reduce the federal government’s liability, and better align pricing incentives.