Ability Maine: Hold Your Medicare Part D Plan Accountable

Hold Your Medicare Part D Plan Accountable

The Cruelest Month?

(This item reprinted from Asclepios, Volume 6, Issue 13. It has been slightly edited. Links will take you to Medicare Rights Center pages — some are PDF files. Steve Hoad, Editor)

The three–month grace period that people with Medicare received under the new Part D drug benefit comes to an end April 1. The mandate to provide temporary supplies of off–formulary drugs (medicines plans do not cover) comes to an end. Restrictions and limits on certain drugs that plans had temporarily lifted will again be imposed.

The AARP plan web site warns, "As early as April 1, 2006, non–formulary, covered drugs will no longer be covered under our plans, prior authorization regulations will go into effect, and Step Therapy programs will be re–instituted." (Step therapy denies coverage until the patient first tries an alternative medicine. If that drug is shown to be ineffective or cause side effects, the plan should cover the drug originally prescribed.)

AARP goes on to urge enrollees to use the transition period to switch to a covered drug or to fill out paperwork to obtain coverage. Information on how to appeal for coverage, such as fax numbers and forms, is not made readily available. It remains buried in the "appendix" section of the AARP web site, weeks after advocates for people with Medicare urged AARP and its partner, United HealthCare, to display the information more prominently.

That kind of obstructionism makes it doubtful that, by the end of March, people with Medicare will receive coverage for the drugs they need. Unfortunately, AARP/United HealthCare is not the only Part D plan erecting barriers to coverage. Part D plans have financial incentives to deny or restrict coverage, and the Centers for Medicare & Medicaid Services (CMS) has not provided the oversight and enforcement needed to make plans play by the rules. As a result, Part D plans fail to provide the security and consistency of coverage that people have come to expect from Original Medicare. Here is an illustrative case that the counselors at the Medicare Rights Center have been trying to resolve.

Ms. A has Medicare and Medicaid and is enrolled in two Part D plans and still has not been able to get her drugs covered for two weeks. She is now out of medicine. The first plan, GHI, refused to cover her diabetes medicines, even though the transitional period was still in effect. She switched to UniCare because it covered her drugs, but that plan has refused to recognize her Medicaid eligibility and is charging copayments well above the $3 maximum she is supposed to pay.

Weeks ago, in MidMarch, CMS urged Part D plans to take a number of steps to make sure the transition period is effective, including informing enrollees about appeals rights and procedures, adequately manning call centers, and making "case–by–case" arrangements for continuing to fill prescriptions for off–formulary or restricted drugs.

Unfortunately, the record of drug plans over the last three months provides no confidence that they will take these steps. Plans have been inconsistent in following CMS instructions to provide transitional supplies or to ensure that low–income people with Medicare and Medicaid are not overcharged.

CMS has been reviewing data to ensure plan transition processes have been effective. If the data does not show that the medicines people with Medicare need will be covered beginning in April, then CMS needs to make sure that temporary supplies are extended and the transition process continues.

The other lesson learned over the last three months is that CMS will downplay or ignore problems unless there is a public outcry

If you or someone you know experiences problems filling prescriptions from a Part D plan, make some noise. You can write a letter to the editor. You can call your senator or representative. And you can tell your story to the Medicare Rights Center (http://www.kintera.org/TR.asp?ID=M715403128099374125884965). Please do not forget to mention your Part D plan by name. The plans need to be held to account.

"The purpose of the transition process is not simply to provide a temporary supply of non–formulary drugs during a certain period of time but, rather to provide your enrollees with sufficient time to work with their health care providers to switch to a therapeutically appropriate formulary alternative or to request a formulary exception on the grounds of medical necessity. At the same time, it is vital that your enrollees be given clear guidance regarding how to proceed after a temporary fill is provided so that an appropriate and meaningful transition can be effectuated before the end of the transition period" ("Memorandum To: All Part D Sponsors," Centers for Medicare & Medicaid Services, March 17, 2006).

Because many people with Medicare had problems obtaining their medicines during the first months of the drug benefit, most states offered stopgap coverage to people with both Medicare and Medicaid, and CMS extended the transitional period during which drug plans were supposed to provide temporary supplies of medications not on a plan's list of covered drugs. In most states, both those safety nets end in March, and there will be widespread denials of needed drugs in April?(In Maine, people on Medicare and Medicaid are covered for these drugs.

If you have Medicare and Medicaid call 1–866–rxMaine 796–2463. Ed.) a situation exacerbated by a nonfunctioning appeals process ("Medicare Part D Appeals System Breaks Down (http://www.kintera.org/TR.asp?ID=M715403308099374125884965)," Medicare Rights Center, March 2006).

(For assistance with Medicare D appeals call Maine's Disability Rights Center, 1–800–452–1948 (v/tty) For clients and their families 1–207–626–2774 (v/tty))

"My plan does not cover the full prescription of one of my medications, Lotrel. It imposes a quantity limit. My doctor said I must take one Lotrel in the morning and another in the afternoon. My doctor tried to work with my Part D plan to get the 60 capsules per month. I have also called.

My plan did not approve the prescription. I am on a very limited income. How can I convince them I can't afford to buy 30 capsules a month? I was on a patient assistance program before Part D, and I got a few months ahead, but after that runs out what am I supposed to do?" ("Restricted by Quantity Limits (http://www.kintera.org/TR.asp?ID=M715403488099374125884965)," from Cookeville, TN, March 2006)

Fast Relief: Participate in an Upcoming Citizens' Health Care Working Group Meeting

For the first time, the federal government is asking all Americans what they think is important for health care to work for everyone in the United States. Make your voice heard by participating in one of the upcoming Citizens' Health Care Working Group meetings being held across the country and over the internet. These meetings are being held to hear how you would "provide every American with the ability to obtain quality, affordable health care." The opinions of all participants will then be presented as recommendations to Congress and President Bush in the fall of 2006. (PDF link!) http://www.medicarerights.org/Makinghealthcarework.pdf
(http://www.kintera.org/TR.asp?ID=M715400638099374125884965)

Asclepios'named for the Greek and Roman god of medicine who, acclaimed for his healing abilities, was at one point the most worshipped god in Greece, a weekly action alert designed to keep you up'to'date with Medicare program and policy issues, and advance advocacy strategies to address them.
(reprinted on AbilityMaine by permission of the Medicare Rights Center.)

The Medicare Rights Center (MRC) is the largest independent source of Medicare information and assistance in the United States. Founded in 1989, MRC helps older adults and people with disabilities get good, affordable health care.