Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

Streamlining Part D Exceptions and Appeals

September 26, 2013

Medicare Rights Recommends Improvements to Part D Exceptions and Appeals

Last week, the Medicare Rights Center submitted a letter to the Medicare Payment Advisory Commission (MedPAC) that included recommendations to improve Part D exceptions and appeals. Medicare Rights knows firsthand the challenges that Medicare beneficiaries face when managing their own exceptions and appeals under Part D. Each year, Medicare Rights addresses more than 5,000 questions from beneficiaries, caregivers and services providers seeking help with Medicare appeals and related legal matters, and the Centers for Medicare & Medicaid Services (CMS) lists Medicare Rights on its standardized notice of coverage denial, which Part D plans are required to use.

In the letter, Medicare Rights recommends that information pertaining to the Part D exceptions and appeals process is clearer and provided sooner to beneficiaries. Currently, Medicare beneficiaries who are refused a drug at the pharmacy counter do not receive individualized information about the reason a drug is being refused. Medicare Rights also recommends that the Part D exceptions and appeals process be streamlined and expedited by combining the refusal at the pharmacy counter with the formal request for a coverage determination. Instead of being required to formally request a coverage determination after leaving the pharmacy, Medicare beneficiaries would be able to initiate the coverage determination request at the pharmacy counter. The letter also explores other opportunities or interim steps to improve Part D appeals, such as eliminating the redetermination phase of an appeal or trigging an automatic plan inquiry to the prescribing physician when a prescription is refused at the pharmacy counter.

The letter to MedPAC also includes recommendations around data collection and transparency: Medicare Rights encourages MedPAC to suggest that CMS measure plan performance at all levels of the appeals process and also make these plan-level data available to the public. Additionally, Medicare Rights encourages MedPAC to examine available data, in order to better ascertain how many beneficiaries are able to successfully process an appeal and how beneficiaries cope with delayed or limited access to prescribed medications while navigating the exceptions and appeals process.

Read the letter.

Advocates Comment on Plans to Integrate Care for Dual Eligibles

This week, the Coalition to Protect the Rights of New York’s Dually Eligible (CPRNYDE) submitted comments on the Fully Integrated Duals Advantage (FIDA) demonstration Memorandum of Understanding (MOU) between the Centers for Medicare & Medicaid Services (CMS) and the New York State Department of Health (NYSDOH). In its letter, sent to both the NYSDOH and CMS, CPRNYDE addressed positive aspects of the MOU, as well as specific concerns and opportunities for improvement. CPRNYDE also requested that consumer advocates be involved in ongoing implementation discussions in real time, including the negotiation of the contract between the State, CMS and the private plans that will provide integrated Medicare and Medicaid services under the FIDA demonstration.

CPRNYDE commented on a variety of provisions in the MOU, including the integrated appeals process, care coordination, the Participant Ombudsman, compliance with the Americans with Disabilities Act (ADA) and quality measures.

Integrated Part D Appeals – CPRNYDE applauded the State and CMS for including aid continuing for all prior-approved Medicare and Medicaid benefits pending appeal. CPRNYDE stated that at a minimum, CMS and the State should collapse the multiple levels of Part D plan appeal and ensure that a denial of coverage given at the pharmacy counter is treated as a coverage determination and that the beneficiary is given immediate appeal rights.

Continuity of Care – CPRNYDE recommended that in the contract between New York State, CMS and the FIDA plans (the “Contract), New York adopts at least the 180-day transition period used in other states, as communications and processes that will take place between plans, providers and enrollees will take more time than the 90-day transition period affords.

Passive Enrollment – The MOU refers to an “intelligent assignment” algorithm that will be used for passive enrollment, and will prioritize continuity of providers and/or services. CPRNYDE wrote that the Contract include more detail on how the algorithm works, and also ensure that the algorithm considers Participants’ previous service and provider utilization in both Medicare and Medicaid.

Participant Ombudsman – According to CPRNYDE, the Contract should allow the Ombudsman to routinely receive and have access to data that the plans report to the State or CMS, and the Ombudsman must have authority to ask questions of the plans about participants regardless of whether a particular participant has provided authorization, and about procedures, systems, and data.

Cultural Competency and ADA Compliance – While the MOU does make some reference to the ADA, the Civil Rights Act of 1964, and the Supreme Court’s Olmstead decision, CPRNYDE wrote that the MOU’s language is very vague in these areas and that more concrete ADA compliance standards should be created.

Quality – In its comments, CPRNYDE wrote that the State should create a reporting system based on the quality measures specified in the MOU as the basis for Quality Withholds.

Read CPRNYDE’s comments.

Volume 4, Issue 38

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Medicare Reminder

A Special Needs Plan (SNP) is a Medicare Advantage plan (private health plan) that exclusively serves at least one of the following groups:

  • People who live in a nursing home or Intermediate Care Facility for the Mentally Retarded (either specific nursing homes or those in a certain area) and people who live in the community but require an institutional level of care;
  • People who have both Medicare and Medicaid (dual-eligibles); and
  • People who have a specific chronic, severe or disabling condition defined by the plan (such as diabetes or heart disease).

SNPs should be designed to provide Medicare-covered health care and services that meet the special needs of people in the groups they serve. Examples of Special Needs Plans include plans for people with HIV/AIDS, diabetes or people who have both Medicare and Medicaid.

SNPs must include drug coverage (Medicare Part D) as part of their benefits packages.

Learn more about Special Needs Plans at




According to the U.S. Department of Health & Human Services (HHS), enrollment in Medicare Advantage (MA) plans is expected to increase for the fourth straight year, and 99.1 percent of Medicare beneficiaries will have access to a plan in 2014. As enrollment increases, MA plan quality continues to improve—over one-third of MA plans will have four or more stars in 2014. The MA and Part D plan star ratings, created by the Affordable Care Act (ACA) and developed by the Centers for Medicare and Medicaid Services (CMS), help individuals compare and chose plans. CMS figures star ratings on a scale of 1 to 5. To receive the best rating of 5, MA and Part D plans must have both high quality and high performance.

Since the ACA was enacted in 2010, seniors and people with disabilities have seen a plan market with lower average premiums, higher enrollment, and lower prescription drug costs. And in 2014, the Part D doughnut hole will continue to close with coverage of brand name drugs staying at 52.5 percent of the cost of the drug in the doughnut hole, while generic drug coverage will increase to 28 percent of cost.

“On the eve of full implementation of the ACA, the stability of the Medicare Advantage and Medicare prescription drug plan market in 2014 is welcome news to Medicare beneficiaries, who in general will have similar access to plans as they have in years past. As the ACA strengthens Medicare Advantage and prescription drug plans, beneficiaries continue to be protected from significant increases in costs, benefits remain stable and access to plans is strong,” said Joe Baker, President of the Medicare Rights Center, in a recent press statement.

Read the HHS press release.

Read Mr. Baker’s statement.


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