Archive
Weekly Email: Week of February 6
I. Conference Call Information (February 8, February 22, 2006)
II. In the News
HHS Secretary Issues One Month Progress Report on Part D
McClellan Calls for Part D Transition Period Extension
OIG Report on Duals and Part D Formularies
Federal Funding for High Risk Pools
Settlement Reached in Suit on Behalf of Developmentally Disabled Medicaid Beneficiaries
Judge Rules that Massachusetts did not Provide Adequate Care to Emotionally Disturbed Medicaid Beneficiaries
III. Helpful Information
CMS to Reimburse States for Part D Payments
CMS Releases Guidance on Niacin Products
CMS Tip Sheet Encourages Early-in-Month Enrollment
IV. HAP Resources
Updated Cost Sharing Chart
Correction: Poverty Line Charts
Updated "Handling Problems for Duals"
V. Other Resources
Formulary Tool Available
New Screening Tool for “Pickle People”
I. Conference Call Information
The next Medicaid conference call, "Changes Ahead in Medicaid and the New Direction of HAP," will be held on Wednesday, February 8th at 3:00 p.m. EST. The federal budget reconciliation agreement, approved February 1, 2006, includes a number of significant changes to the Medicaid program. Families USA health policy and field staff will join us to talk about the timetable for the changes that lie ahead. We also will discuss how you can prepare for consumer assistance to address these changes. Background information is now posted on our website.
We will also talk about a change in the direction of HAP. As you may know, HAP was initially created under a generous grant from the Robert Wood Johnson (RWJ) Foundation that allowed us to serve programs that work on a variety of health coverage and access issues. HAP’s work under the RWJ grant was completed on December 31, 2005. HAP has secured ongoing funding which focuses on SHIPs and their network partners that serve senior Medicare beneficiaries. Nevertheless, our parent organization, Families USA, will continue to meet some of the needs of non-SHIP consumer assistance programs, while seeking additional funds to support that work. The February 8th conference call will discuss the transition of services from HAP to Families USA. We invite consumer assistance programs that focus primarily on Medicaid to talk with some key Families USA staff members about how we can help each other in 2006 and beyond. For more information, contact Cheryl Fish-Parcham, cparcham@healthassistancepartnership.org.
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HAP’s next Medicare conference call will be on Wednesday, February 22, 2006, at 3:00 p.m. EST. We are moving it to the fourth Wednesday of this month to avoid a conflict with the first Open Door Forum call with Dan Schreiner, the Medicare Beneficiary Ombudsman, on February 15. We plan to schedule future calls on the third Wednesday of the month, as in the past. HAP’s February Medicare call will continue the discussion of how SHIPs and other advocates can help beneficiaries obtain their prescriptions through their Part D plans. We will provide updates on the emergency procedures that CMS has put in place to help beneficiaries through Part D start-up issues. We also plan to discuss more long-term issues related to coverage determinations, exceptions and appeals. Please send any questions or suggestions to Kelly Brantley, kbrantley@healthassistancepartnership.org, or Hilary Dalin, hdalin@healthassistancepartnership.org.
The next private insurance call is scheduled for Wednesday, February 22 at 1:00 p.m. EST. We have several requests for discussion on how to help consumers in self-insured plans. Since states do not actually have regulatory authority over these plans, some programs report problems in getting the plans to cooperate with their efforts to resolve consumers' problems. If you have had successes in this regard that you would like to share with other programs, please write to Cheryl Fish-Parcham, cparcham@healthassistancepartnership.org. (Cheryl will soon be joining Families USA's health policy team to work on private insurance health policy issues, and she hopes to continue some assistance to the private insurance consumer assistance programs in HAP's network.)
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II. In the News
HHS Secretary Issues One Month Progress Report on Part D
Health and Human Services Secretary Mike Leavitt issued the “Secretary’s One Month Progress Report on the Medicare Prescription Drug Benefit” on February 1, 2006. The generally upbeat report acknowledges that the Centers for Medicare and Medicaid Services (CMS) has run into some “unanticipated problems.” The Secretary notes that CMS is “intensely focused” on fixing problems that include increasing the number of people who have a successful experiences the first time they go to a pharmacy after enrolling, resolving the difficulties that dual eligibles face along with related data transmission “imperfections,” encouraging plan enrollment early in the month, and shortcomings in customer service. The Secretary also announced that Medicare would notify the drug plans that it is extending the 30-day transitional coverage period for 60 more days (see “McClellan Calls for Part D Transition Period Extension,” below).
McClellan Calls for Part D Transition Period Extension
In a Memorandum sent to the Part D drug plans on February 2, 2006, CMS Administrator Mark McClellan issued a call for a 60-day extension of the Part D transition period. McClellan, however, stopped short of declaring a mandatory extension. Citing the need for duals to learn how the new system operates, he wrote, “I am calling for a one-time across the board extension of the transition period to March 31 for those individuals who were enrolled in the first few months of the program.” He noted that the extension would benefit beneficiaries, plans and providers alike, and asked the plans to reply to CMS by close of business on February 6 with their “intention to implement this transition policy.”
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OIG Report on Duals and Part D Formularies
The HHS Office of Inspector General (OIG) released a report on January 26, "Dual Eligibles Transition: Part D Formularies' Inclusion of Commonly Used Drugs", which concludes that 30 percent of dually eligible persons (duals) have been assigned to plans that cover less than 85 percent of the drugs they most commonly use. The report states that many beneficiaries will need to take action to either get an alternative prescription, to request an exception, or change plans. OIG also observes that many beneficiaries will need help in this process. OIG notes that at the time of its interviews, four states had decided to provide some wrap-around coverage for duals whose physicians prescribe non-formulary Part D drugs. Connecticut and New York will cover drugs that are not on the drug plan formulary if the state covers the drug for non-duals. New Jersey and Vermont will each cover a limited group of non-formulary drugs. Note that this wrap-around coverage for non-formulary drugs is in addition to the temporary stopgap coverage that many states are providing to duals that face Part D transition problems. It is unclear, however, if New York will continue to provide wrap-around coverage during its next fiscal year.
A table on page 20 of the OIG report shows the drugs that at least 25 percent of plan formularies omit. A table on page 37 provides information about 200 drugs that Medicaid beneficiaries most commonly use. The report also includes state-by-state information on the number of duals auto-assigned to plans that cover less than 85 percent of commonly used drugs.
Federal Funding for High Risk Pools
Congress approved legislation (H. R. 4519) on February 1, 2006 that will provide seed grants to states that do not currently have high risk pools. Those states could apply for $1 million grants to establish a high-risk pool. The bill also contains continued funding to offset the operational losses of existing high-risk pools. The President is expected to sign the legislation.
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Settlement Reached in Suit on Behalf of Developmentally Disabled Medicaid Beneficiaries
Kentucky Protection and Advocacy and the Kentucky Cabinet for Health and Family Services settled a class action lawsuit through an agreement that will increase funding for Medicaid services for people with developmental disabilities. The settlement agreement, which will go to final hearing in about two months, will increase funding for community living as an alternative to institutional care, supportive services for those in community living, and crisis intervention services. It will settle the case, Michelle P. v. Birdwhistell, E.D. Ky., No. 3:02-cv-00023.
Judge Rules that Massachusetts did not Provide Adequate Care to Emotionally Disturbed Medicaid Beneficiaries
In the case Rose D. v. Romney, D.Mass., No. 01-30199, January 26, 2006, a federal judge ruled in favor of eight low-income families, finding that Massachusetts violated the federal Medicaid Act. By not providing medical assessments and services, or in-home services, to children with serious emotional disturbances, the state failed to meet Medicaid’s early and periodic screening, diagnosis, and treatment (EPSDT) provisions. The Center for Public Representation provides materials about the case on its website.
III. Helpful Information
CMS Postings
CMS to Reimburse States for Part D Payments
In a letter to State Medicaid and State Pharmacy Assistance Program (SPAP) Directors, CMS on February 2, 2006 announced a demonstration project under which the agency will reimburse states for their payments between January 1 and February 15, 2006 on behalf of duals, when efforts to bill a PDP failed. CMS also said that it will reimburse the states for certain administrative costs that they incurred in the process. There are links to the letter and a related fact sheet and application template on CMS’s new “Repayment to States” web page.
CMS Releases Guidance on Niacin Products
On February 3, 2006, the CMS released guidance on certain prescription products containing niacin. This guidance clarifies that these products, including Niaspan and Niacor, are considered prescription vitamins and, as such, are excluded from Part D coverage. While this guidance is not currently available online, please send requests for this document to Kelly at kbrantley@healthassistancepartnership.org.
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CMS Tip Sheet Encourages Early-in-Month Enrollment
Following up on a concern that Secretary Leavitt described in his Part D progress report (see “HHS Secretary Issues One Month Progress Report on Part D,” above), CMS this week issued a Tip Sheet to address the administrative problems arising from Part D plan enrollment later in the month. The new “Encouraging Early-in-Month Enrollments” Tip Sheet states that “enrollments later in the month make it far less likely that all of the information needed to file the claim correctly will be available at the pharmacy or the plan.”
IV. HAP Resources
Updated Cost Sharing Chart
HAP has updated its Resource Center for Low-Income Beneficiaries. Of note is the chart entitled “Medicare Part D: Cost Sharing for Low-Income Beneficiaries.” The update includes the new Federal Poverty Levels as well as a different format. Please address any comments about the chart to Kelly at kbrantley@healthassistancepartnership.org or 202-737-6340.
Correction: Poverty Line Charts
We fixed an error in our 2006 monthly poverty guideline charts. If you printed the charts after we posted them last week, please return to our website to get the corrected version.
Updated "Handling Problems for Duals"
HAP updated its sample instructions on Handling Common Problems for Duals to address recent CMS transmissions that extend the transitional coverage period for 60 more days through March, and that clarify that Medicare covers some drugs, such as IVs administered via an infusion pump, under Part B, not Part D. Thus, if a drug plan says that a drug is not covered under Part D, the pharmacist can bill Medicare directly for Part B drugs, or Medicaid for some other excluded drugs that are still covered by the state's Medicaid program.
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V. Other Resources
Formulary Tool Available
The California Health Foundation (CHF) and California Medical Association announced on February 3, 2006 that they are offering a Palm handheld computer that contains the formulary information for more than 90 Part D plans in that state. CHF is selling the hand-held for $99.
New Screening Tool for “Pickle People”
People who received both a regular Social Security check (OASDI) and SSI in any month after 1977, but who then lost SSI due to a Social Security cost-of-living increase, may still be eligible for Medicaid under the Pickle Amendment. The National Health Law Program has a fact sheet on its website, "A Quick and Easy Method of Screening for Medicaid Eligibility under the Pickle Amendment.” Gordon Bonnyman of the Tennessee Justice Center wrote the two page screening tool. It will help you determine if a client is eligible for this coverage. Go to www.healthlaw.org and look under "What's New."
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