Part D Consumer ProtectionsFrom: Asclepios June 21, 2007 . Volume 7, Issue 25 The companies offering the Part D prescription drug benefit have a financial incentive to deny coverage for expensive medications and to discourage enrollment by people with Medicare who have high drug costs. That's not a mistake; that is a fundamental part of how Part D was designed to work. Rather than provide the drug benefit directly through Medicare and using the purchasing power of 43 million people with Medicare to negotiate lower drug prices, Congress handed the benefit over to private companies and put them at financial risk for the drug costs of their enrollees. Financial risk means Part D plans have a strong incentive to keep costs down, including through policies that have the potential to harm the health of their members. Recognizing that these incentives could hinder access to the medicines people with Medicare need, Congress established some basic consumer protections under Part D. A hearing today [June 21, 2007] by the House Ways and Means Health Subcommittee examines how these consumer protections are working. The testimony from the Medicare Rights Center, the Center for Medicare Advocacy and the Alta Bates Summit East Bay AIDS Center shows that there are serious gaps in protections. In particular, Congress needs to streamline and inject some basic fairness into the process for appealing when a Part D plan denies coverage for a medicine. After having a prescription rejected at the pharmacy counter, people with Medicare now have to ask their plan twice for coverage before they receive an independent review. Asking the plan the second time to review its decision is almost always a waste of time. People with Medicare need speedy access to an independent review where they have a shot at a fair assessment of their medical needs. Enrollment protections are also woefully lacking. People with Medicare have no due process rights if they are dropped from their Part D plan. People with Medicare who need expensive medicines in particular are at risk from plans looking for ways to purge their rolls of high-cost enrollees. Congress should also lift lock-in, which prevents most people from changing plans during the course of the year. This past January, when it was too late to switch plans, scores of people with Medicare found out at the pharmacy counter about changes to their coverage for 2007. Important as they are, these improvements to the Part D consumer protections are stop-gap measures, however. The real way to protect people with Medicare is to provide them with the choice of obtaining coverage directly through Medicare, the same government-administered program that has provided good, reliable health coverage for millions of Americans for over 40 years. Medical Record "We recommend that Congress take action to streamline the Part D appeals
process and ensure access to medically necessary drugs, including for
off-label uses that have proven to be clinically effective. Enrollment
protections for people with Medicare, including the removal of lock-in for
Part D and the Medicare Advantage program, should also be enacted. Finally,
Congress should direct CMS to exercise its oversight and enforcement
responsibilities so that the protections afforded people with Medicare on
paper are in fact provided by the Part D plans" (Testimony of Paul Precht,
Deputy Policy Director of Medicare Rights Center "I was recently prescribed Prevacid, which my Part D plan tells me will not
be covered. They say I must use the weaker over-the-counter medication
first. I am taking blood thinners following angioplasty. If I should develop
bleeding from my stomach, I die. I already know the over-the-counter
medicine will not be effective in addressing my stomach disorder. The full
strength Prevacid wasn't even effective unless I took double the dosage. The
plan insists that only a letter from my doctor will instigate an appeal. My
doctor has a practice that is very heavy with Medicare patients. I have been
informed that he can no longer write letters justifying his prescription
decisions when insurance companies reject coverage of the drugs. He needs
some time to practice medicine instead. I was recently released from the
hospital after angioplasty. I have a defibrillator/pacemaker because of
advanced heart disease. I was really in no condition to argue with 'customer
relations' workers questioning the medical treatment prescribed by a
licensed physician with 30 years' experience" (Story submitted to the Part D
Monitoring Project "The Part D regulations, however, specifically downgrade the effect of the
physician's opinion to such an extent that it is not clear whether any
deference is given. Thus, while beneficiaries must obtain a supporting
document from their physician even to enter the exceptions process, Part D
plans are not required to respect the physician's opinion. Plans ignore or
discount medical records submitted by doctors. Some are not satisfied that a
formulary drug is ineffective for a beneficiary, for example, unless their
own claims history for the beneficiary, and not the doctor's medical records
for that individual, show ineffectiveness" (Testimony of Vicki Gottlich,
Senior Policy Attorney with the Center for Medicare Advocacy * * * * Medicare Part D Appeals Help for Advocates is here! MRC's new "Medicare Part D Appeals: An advocate's manual to navigating the Medicare private drug plan appeals process" offers an easy-to-understand, comprehensive overview of the entire appeals process, including real-life case examples, a glossary of important appeals terms, a sample protocol for advocates, and links to important resources. Register for a FREE copy * * * * Fast Relief: Part D Monitoring Project The Medicare Rights Center (MRC) needs to hear about all the problems with the Medicare Part D benefit, whether they happen to you or someone in your community. With this information, we will be armed with the needed evidence to push for a decent Medicare drug benefit. Submit your story at http://www.medicarerights.org/partdstories.html. * * * * The Louder Our Voice, the Stronger Our Message 062907
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