30 Policy Goals for Medicare’s Future


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Category: Streamline and Simplify Appeals Processes

Improve Pharmacy Counter Communications with Beneficiaries

Knowing why a prescription drug is denied 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. All Part D plans should be required to provide an individually tailored denial notice at the pharmacy counter, explaining why the prescription cannot be filled. Further, this notice should count as a coverage determination—eliminating a needless step in the appeals process for Medicare beneficiaries.

Improve Medicare Advantage and Part D Denial Notices

Among the most common calls to the Medicare Rights helpline are those from beneficiaries who were denied access to a health care service or prescription medication and don’t know how to proceed. Congress should require CMS to ensure Medicare Advantage and Part D plan denial notices include the correct information (including clinical content), are available in languages other than English, and are accessible to diverse health literacy levels.

Allow Independent Redeterminations

The first level of appeal following a plan’s initial decision must be a truly independent and good-faith effort to determine coverage eligibility. This would better ensure that plans are accurately effectuating their coverage determination decisions. Congress should pass legislation requiring that a plan’s initial coverage decision be reviewed by an independent entity, rather than the plan itself. In addition, overturned decisions must trigger a review of the file and necessary employee training.

Improve Transparency, Data Collection, and Plan Oversight

All Part D appeals conversations are hampered by limited data and transparency in the process. Beneficiaries and advocates alike can struggle not only to track an individual’s specific claims, but also plans’ or system-wide patterns that may be tied to hundreds of thousands of Medicare beneficiaries improperly going without their needed medication. Further, better data could lead to better solutions, as a more transparent system will lend itself to targeted recommendations and self-correction. Congress should require CMS to conduct and make publicly available a comprehensive, in-depth analysis of the Part D appeals process. In part, this analysis should include data […]

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.