Archive
Beginning April 1, 2006, the mission of HAP is to work with State Health Insurance Assistance Programs (SHIPs) to enhance the efficiency and effectiveness of their programs so they can provide high-quality education and counseling to a greater number of seniors about Medicare and related health care coverage. An additional HAP goal is to stabilize and increase federal funding for the SHIP network. Because HAP will no longer be focused on health insurance issues that affect the non-Medicare population, the weekly emails may not be relevant to your program. We invite you to continue receiving our emails; however, if you prefer not to receive them, please send an email to webmasterga@healthassistancepartnership.org with “UNSUBSCRIBE” in the subject.
I. Conference Call Information
II. In the News
SSA Chart on Completed LIS Decisions Now Available
Thirty Million Now Receiving Part D Drug Coverage
Late Enrollment Surge Jams Drug Plans’ Phone Lines
III. Helpful Information
CMS and Partners Release Standardized Pharmacy Codes
New Part D Coverage Determination Request Form for Prescribing Physicians Released
Low-Income Subsidy (LIS) Enrollment Opportunity
CMS Issues Guidance on Part D Formulary Changes During Plan Year
I. Conference Call Information
The next Medicare conference call will take place on Wednesday, May 17. Look for details about the upcoming call in next week’s edition of HAP’s weekly e-mail.
II. In the News
SSA Chart on Completed LIS Decisions Now Available
The Social Security Administration (SSA) released a chart that details
the completion status of Low Income Subsidy (LIS) applications received as of March 31, 2006. The chart includes state-specific information displaying number of applicants per state, status of decisions, number of beneficiaries who are eligible, and percentage of applications that have been processed. SSA’s chart shows that its completion rates range from 92.4 percent for LIS applicants from Tennessee to 100 percent for those from Vermont. Nationally, SSA reports that it has processed 96.6 percent of the 4,739,904 applications it has received.
Thirty Million Now Receiving Part D Drug Coverage
On April 20, CMS announced that the number of Medicare beneficiaries receiving prescription drug coverage through Part D drug plans has reached nearly thirty million. Eight million of these are enrolled in plans offering individual prescription drug coverage, including one million whose enrollment CMS has facilitated. For more details, see CMS’s press release.
Late Enrollment Surge Jams Drug Plans’ Phone Lines
This past Monday, April 24, the New York Times reported that Part D drug plans are expecting a surge in enrollment activity before the May 15 initial enrollment period deadline “that threatens to overwhelm already busy phone lines and leave beneficiaries struggling to figure out how to sign up for the new plan.” The article described the results of a federal contractor’s calls to Part D plans to measure the recent performance of the plans’ call centers. The contractor’s test calls found that many plans are falling short of the CMS standard requiring answers within 30 seconds to 80 percent of the calls. Callers to one plan reportedly waited as long as 30 minutes to reach a customer service representative. The implications for SHIPs are to: 1) encourage clients who want to enroll in a Part D plan to do so as soon as possible, 2) use Medicare’s or the plan’s web-based enrollment tools to save time, and 3) expect to wait when calling plans’ general customer service phone lines.
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III. Helpful Information
CMS Postings
CMS and Partners Release Standardized Pharmacy Codes
CMS has collaborated with America's Health Insurance Plans (AHIP), the National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA) to create a standardized coding messaging system for pharmacists for all Part D plans to use. The standardized electronic messaging will help pharmacists determine the proper course of action for filling beneficiaries' prescriptions in four common situations. The situations are when 1) the plan does not cover a particular drug, 2) the plan requires prior authorization, 3) the plan’s quantity or other coverage limitations have been exceeded, and 4) the pharmacy does not belong to the plan’s network. The purpose of this initiative is to decrease confusion and increase efficiency in transactions between pharmacists, beneficiaries and their Part D plans.
Coinciding with this release, CMS administrator, Dr. Mark McClellan, announced the creation of the Pharmacy Quality Alliance (PQA). The alliance will consist of representatives from the pharmacy community, health plans, government, employers, physicians, and consumer groups. The PQA’s main objective will be to create strategies "for measuring and reporting data that will help consumers make informed choices and appropriate healthcare decisions." For more details about any of the above, see the PQA information package (scroll down for specifics on standardized coding).
New Part D Coverage Determination Request Form for Prescribing Physicians Released
Last week the American Medical Association (AMA) and America's Health Insurance Plans (AHIP), in collaboration with CMS, released a model coverage determination request form. It represents the efforts of physicians, insurers, Medicare officials and beneficiary advocates to develop a practical determination request form for physicians’ use. The new form’s purpose is to create a less cumbersome and more efficient process for prescribing physicians who are requesting exceptions and prior authorizations on behalf of Medicare beneficiaries. The form, however, was not designed to request Medicare non-covered drugs, biotech or specialty drugs for which the plans require specific forms, or out-of-network pharmacy coverage determinations. Finally, the new form was not designed for use by beneficiaries. CMS’s “Request for Medicare Prescription Drug Coverage Determination” form, issued in February this year, is still available for these other purposes.
Low-Income Subsidy (LIS) Enrollment Opportunity
On April 20, CMS announced that Medicare beneficiaries who qualify for LIS, or “Extra Help,” after May 15, 2006 will have a special enrollment period (SEP). This SEP will give qualifying beneficiaries a one-time opportunity to enroll in a prescription drug plan if they have not already done so. CMS explained that this differs from extending the open enrollment period (OEP), because this SEP will give LIS qualified beneficiaries a one-time opportunity to enroll when they qualify. Medicare will continue to facilitate enrollment for those among this population who do not choose a plan. This is good news for SHIPs and others who plan to continue their outreach efforts to enroll limited income beneficiaries in the Extra Help program throughout the year.
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CMS Issues Guidance on Part D Formulary Changes During Plan Year
On April 27, Abby Block, the Director of CMS’s Center for Beneficiary Choices, issued a memorandum to Part D plan sponsors with guidance on Medicare policy regarding formulary changes during the plan year. In an apparent effort to balance the need for formulary stability and cost-containment, CMS declared that “no beneficiaries will be subject to a discontinuation or reduction in coverage of the drugs they are currently using, except for clear scientific and costs reasons including the availability of a new generic version of the drug or new FDA or clinical information.” The memo provides details on the agency’s four part policy regarding formulary changes, including “formulary maintenance changes” and “other formulary changes.”
Ms. Block stated that CMS generally will give “positive consideration” to formulary maintenance changes such as the removal of a brand name drug provided the plans add an A-rated generic or multi-source equivalent at a lower cost for beneficiaries. CMS also would view favorably additional utilization management tools that give effect to “other approved formulary changes (e.g., prior authorization on a brand drug when generic is now available on formulary at a lower cost), to help determine B vs. D coverage (subject to CMS guidance on least burdensome ways to make this determination), or to promote safe utilization of a Part D drug based on new clinical guidelines or information.”
Plan sponsors who want to add utilization management tools to their formularies for reasons other than those noted above, or make formulary changes such as removing dosage forms or exchanging therapeutic alternatives, can do so “only if enrollees currently taking the affected drug are exempt from the formulary change for the remainder of the plan year.” Ms. Block indicated that CMS will carry this policy forward into 2007 and beyond, in part to prevent the appearance of “bait and switch” in Part D plan formularies. The memo also reiterated CMS’s 60 day notice requirement for most formulary changes, noting that the agency does not require plans to give 60 days notice when removing formulary drugs that a manufacturer or FDA withdraws from the market.
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