Archive
Weekly Email: Week of April 3
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
Next Medicare Call on April 19: Part D Next Steps
II. In the News
CMS Announces 2006-07 SHIP Funding
Medicare Advantage Payments to Rise in 2007
McClellan Meets with Beneficiary Advocacy and Assistance
Organizations
III. Helpful Information
CMS Publishes Final Rule on Power Scooters and Wheelchairs
CMS Releases More Resources on Transition Period’s End
IV. Resources
Pharmacy Counter Resource for Part D Plan Enrollees Available
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I. Conference Call Information
Next Medicare Conference Call on April 19: Part D Next Steps
The next Medicare conference call is scheduled for Wednesday, April 19 at 3:00 p.m. EDT. The Part D transition period is ending and the conclusion of the Part D 2006 Annual and Initial Enrollment Periods is approaching. CMS has enrolled in Part D plans the Medicare Savings Program beneficiaries, SSI beneficiaries and those who applied and were awarded LIS effective May 1st. Join us for our next monthly call where we will discuss the acceleration of the Part D timeline, enrollment periods and plan elections, especially Special Enrollment Periods, and any consequences of the conclusion of the transition period. We will also invite open and in-depth brain-storming about reaching those who will be most hurt if they fail to enroll in a plan by May 15th. We'll share ideas and practical advice to help beneficiaries gain access to drugs through Part D plans, and if time permits, we’ll address Parts B and D coverage issues as well.
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II. In the News
CMS Announces 2006-07 SHIP Funding
CMS announced on April 5th that State Health Insurance Assistance Programs (SHIPs) will receive $30 million in funding to assist beneficiaries in the coming year. According to CMS this funding has nearly doubled since 2003. In 2004, SHIPs received $21 million. With the impending implementation of Medicare Part D, CMS increased the amount to $31 million for 2005. Not all states receive equal funding. Each state, the District of Columbia and Puerto Rico receives a base grant of $75,000. Guam and the U.S. Virgin Islands receive $25,000. The remaining amount of the SHIP grant awarded to each state or territory is then based on an equation that takes into account the percentage of beneficiaries nationwide who live in the state, the proportion of the state's beneficiaries to total state population, and the proportion of beneficiaries who live in rural areas. SHIPs offer an essential service in that they provide personalized, face-to-face counseling for Medicare beneficiaries, many of whom are overwhelmed with decisions they face. According to CMS, over 4.2 million beneficiaries have turned to their local SHIPs for information and assistance about Medicare drug coverage.
Medicare Advantage Payments to Rise in 2007
CMS has announced an average increase rate of approximately four percent for Medicare Advantage (MA) Plans in 2007. According to an April 3rd CMS press release, this increase is due to many factors including current year growth in Medicare costs of 3.6 percent and the phase out of "budget neutrality" adjustments in MA payments. For more information see the accompanying "MA Rate Payment fact sheet".
McClellan Meets with Beneficiary Advocacy and Assistance Organizations
On Thursday, March 30, 2006, Dr. Mark McClellan, Administrator of CMS, invited representatives of several national organizations that work with Medicare beneficiaries--including HAP--to meet with him. During the meeting, Dr. McClellan touched on many topics, including the end of the 90-day Part D transition period and CMS monitoring of plan performance.
As Dr. McClellan discussed the end of the transition period, he emphasized that transition is a process, not merely a fixed period in time. Many of the points that Dr. McClellan made about transition are set forth in a March 30, 2006 Memorandum from Gary Bailey, Deputy Director at CMS’s Center for Beneficiary Choices, to the plan sponsors (See last week’s HAP Weekly E-Mail, dated March 31, 2006, for a summary of this, and another, important memorandum).
Dr. McClellan said that CMS will closely monitor plans for compliance with CMS directives regarding transitions and exceptions and appeals. He stated that the agency will use its authority granted by Congress to sanction plans if appropriate. CMS welcomes specific detailed information about problems in these areas “sooner rather than later” to resolve problems and assist CMS in effective monitoring of plans. He instructed the organizational representatives to use the CMS Regional Office casework system to address urgent beneficiary matters.
Moving on to discuss the future, Dr. McClellan praised collaborative efforts of advocates, providers and plans to create model forms and coding systems. One such effort, that Dr McClellan characterized as being “close to success,” is a form called a “trigger form.” It could be used to request prior approval or a coverage determination, including an exception for most cases. CMS invited HAP’s Kelly Brantley to join the work group that created that form. Other initiatives are underway to develop coding systems that will enable drug plans to give pharmacies clear messages about why prescriptions cannot be filled, and that also explain the next steps to take to get a prescription filled through a utilization management protocol, or an exceptions request.
HAP staff conveyed the need for SHIPs to have timely information before new developments occur (such as moving the facilitated enrollment effective date from June 1st to May 1st). HAP also reiterated the request of many SHIPs for two-way communications with all CMS Regional Office caseworkers and contact persons at the plans to facilitate effective and efficient resolution of problems and issues. We urged Dr. McClellan to continue to convene meetings periodically so that organizational representatives can share ideas and information collectively with senior CMS leadership.
Dr. McClellan and the representatives also covered CMS’s discussions with plans about simplifying utilization management protocols; the need to look at quantity limits, especially for beneficiaries stabilized on very high doses of certain medications like anti-psychotics or pain medications; and developing metrics for beneficiaries to better understand and evaluate Part D plans during the next Annual Enrollment Period. With respect to off-label use of drugs, Dr. McClellan clarified that Part D plans may cover FDA-approved drugs for an off-label use. Part D rules do not automatically prohibit such coverage. The need for all parties to continue to collaborate to increase the participation rate of those beneficiaries eligible for LIS (and who lack other creditable drug coverage) was discussed. CMS also noted that it will focus on rural outreach during April 2006.
A last discussion topic was the ongoing effort to secure continuation of Pharmacy Assistance Program (PAP) assistance for Medicare beneficiaries. CMS advised meeting participants to look for a “break-through” soon. For more information on current PAP assistance for Medicare beneficiaries, see HAP’s chart. CMS also said that SHIP staff members who are interested in seeing PAPs offer assistance to Medicare beneficiaries should contact the PAPs to tell them their views.
For more information from HAP about this meeting, please contact Hilary at hdalin@healthassistancepartnership.org, or (202) 737-6340.
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III. Helpful Information
CMS Publishes Final Rule on Power Scooters and Wheelchairs
The Federal Register for April 5th contained CMS’s final rule implementing the Medicare Modernization Act’s provisions on Power Mobility Devices (PMD). PMD includes power operated vehicles or scooters, and power wheelchairs. The rule sets forth CMS policies and procedures for prescribing, supplying, and billing for PMD. Significantly, the rule scuttles the requirement that a specialist in physical medicine, orthopedic surgery, neurology or rheumatology must prescribe a power scooter as a condition of Medicare coverage. The new rule allows a physician or other treating practitioner who has examined the beneficiary face-to-face to prescribe PMD. The physician or treating practitioner must submit a written prescription for the PMD to the supplier within 45 days of the examination or hospital discharge. The rule also eliminates the need for a completed Certificate of Medical Necessity. Instead, Medicare will now accept supporting documentation from the medical record that clearly supports the medical necessity for the equipment in the beneficiary’s home, and will pay physicians for providing the documents. The new rule will take effect on June 5, 2006. Note that the rule does nothing to change the function-based coverage criteria for Mobility Assistive Devices that CMS set out in a National Coverage Determination issued last May.
CMS Postings
CMS Releases More Resources on End of Initial Transition Period CMS released a transition fact sheet on March 31 that outlines transition policy guidelines and conditions to which Part D plans must adhere through and beyond the end of the initial transitional period. The fact sheet emphasized the importance of plan communications with enrollees, especially with regard to making prompt and timely exceptions and appeals decisions. CMS expects plans to fulfill their contractual obligations in meeting the needs of their enrollees for needed prescription drugs. If they fail to do so, they face the possibility of punitive action, including monetary penalties. Also, detailed in the fact sheet are steps CMS is taking to reach health care providers and pharmacists who play significant roles in transition proceedings.
Also in circulation, is a new CMS tip sheet which lists steps beneficiaries should take if they are having trouble getting their prescriptions filled after the transition period ends. CMS stresses the need to work with physicians and pharmacists to find alternate drugs that the beneficiaries’ drug plans cover.
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IV. HAP Resources
Pharmacy Counter Resource for Part D Plan Enrollees Available
HAP has prepared a short “Pharma-Gram” guide for beneficiaries who are having trouble filling their prescriptions at the pharmacy. It describes steps they should take, including instructions to ask the pharmacist to fax a form to the prescribing doctor with information about the drug plan’s non-coverage decision, and to call a local SHIP for help. The Pharma-Gram is designed as a resource that pharmacists can make available to Part D plan enrollees at the counter or as bag stuffers. We invite SHIPs to add your phone number to the Pharma-Gram and use it in your provider outreach and community education efforts.
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