Archive

Weekly Email: Week of February 20, 2006

I. Conference Call Information (February 22, 2006)

II. Helpful Information
     New Law Creates Waiver Rules for Outpatient Therapy Caps
     VA Issues Fraud Warning
     New Fact Sheet Addresses Transition Policy Extension
     Part D Outreach to Medical Specialty Groups and Long-Term Care Associations
     CMS Tip Sheet Encourages Early in Month Enrollment

III. HAP Resources
         Error in Last Week’s HAP Resources Section

IV. Other Resources
Lawyers to be Volunteer Resource for SHIPs

I. Conference Call Information

The next private insurance call will be held on Wednesday, February 22, 2006 at 1:00 p.m. EST. The topic is, “how to help consumers in self-insured plans.” In particular, we will discuss:

How to get self-funded plans to cooperate with a health assistance program's efforts to resolve consumer problems;
Avenues for resolving problems through the ERISA claims and appeals procedures;
Problems with state and county government self-funded plans, which are exempt from ERISA;
Working with mental health third party administrators; and
Educating employers, employees, and unions about the differences in consumer protections under state-regulated versus self-funded plans.

We have invited a compliance officer from Magellan Health Services to join us for the discussion of mental health appeals, and representatives from AFSCME and SEIU will join our discussion about education on self-funded plans.

Background materials are posted on HAP’s website. If you have suggestions or questions about this call, please write to Cheryl Fish-Parcham, cparcham@healthassistancepartnership.org.

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HAP’s monthly Medicare Conference Call will be held on Wednesday, February 22, 2006 at 3:00 p.m. EST. We will address the topic of the utilization management techniques that Part D plans use, along with the procedures for filing coverage determinations, formulary exceptions, and appeals. The goal of this call is to promote discussion among our participants on these more complex subjects as well as to highlight the importance of these procedures in the near future. Background information will be posted on the February Medicare Conference Call webpage. Please send any questions or suggestions to Kelly Brantley, kbrantley@healthassistancepartnership.org, or Hilary Dalin, hdalin@healthassistancepartnership.org.

II. Helpful Information

New Law Creates Waiver Rules for Outpatient Therapy Caps
The Deficit Reduction Act of 2005 that President Bush signed into law on February 8th, directs the Centers for Medicare & Medicaid Services (CMS) to create a process that allows exceptions to the payment caps on outpatient physical, speech-language, and occupational therapy services from providers other than hospital outpatient departments. The therapy caps, currently set at $1,740 each, took effect again on January 1, 2006 after the latest in a series of moratoria expired.

CMS’s exceptions process applies to services provided on or after January 1, 2006. The process allows providers whose claims have already been denied because of the caps to ask the carrier to reopen and review the claim. For more details, see CMS’s Fact Sheet on Outpatient Therapy Caps.

VA Issues Fraud Warning
Veterans around the country have been reporting fraud attempts by the Patient Care Group, a company which claims that it is now dispensing VA prescriptions. The company tells veterans that they must provide a credit card number to continue to receive their medications. The VA’s public affairs office is distributing a warning flyer.

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CMS Postings

New Fact Sheet Addresses Transition Policy Extension
CMS has released a fact sheet that outlines recent transition policy extensions for enrollees' whose coverage took effect on January 1, 2006 or February 1, 2006. These beneficiaries now have until March 31, 2006 to work with their physicians to switch to covered drugs on plan formularies. It also addresses the protocol for seeking coverage of non-formulary drugs or drugs that require prior authorization.

Part D outreach to Medical Specialty groups and Long-Term Care Associations
To facilitate the process for making Part B and Part D drug coverage determinations, CMS has sent letters to medical specialty groups and long-term care associations in which CMS recommends a series of steps that providers take to help distinguish between drugs that may be covered by Part B as opposed to Part D. Included in the letter to subspecialty groups, is a list of Part B covered oral anti-cancer, oral anti-emetic, and immunosuppressive drugs. The letter to long-term care associations contains this information as well as Part B covered items of durable medical equipment and certain infusion/injectible drugs. These lists are not exhaustive and subject to change.

CMS Tip Sheet Encourages Early in Month Enrollment
On February 10, CMS released a tip sheet geared to partners, with the purpose of “Encouraging Early in Month Enrollment”. The tip sheet describes why it is in a beneficiary's best interest to enroll early in the month. Among the reasons, Medicare and the drug plans should have ample time to update and process an enrollee's information correctly. According to CMS, this will ensure that enrollees receive their membership packets before their coverage becomes effective. The fact sheet also details common problems that beneficiaries face resulting from later in the month enrollment.

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III. HAP Resources

Error in Last Week’s HAP Resources Section
Last week we mistakenly reported that HAP created two of three Medicare drug coverage charts that we posted to HAP’s website. CMS is the source of all three. The charts address the distinctions between drug coverage in Original Medicare and Medicare Part D. We apologize for any confusion the error caused.

IV. Other Resources

Lawyers to be Volunteer Resource for SHIPs
The American Bar Association (ABA), through its Commission on Law and Aging, is encouraging lawyers to volunteer with local SHIPs to help beneficiaries with Part D problems, including coverage determinations and appeals. To promote the effort and to prepare the lawyers, the ABA, along with the Center for Medicare Advocacy and HAP, are co-sponsoring a two-hour long web-cast training entitled “Medicare Part D: A Crash Course for Practitioners,” on Thursday, March 2, 2006, at 1:00 p.m. EST. The trainers include HAP’s Hilary Dalin, Vicki Gottlich of the Center for Medicare Advocacy, and Leslie Fried from the ABA’s Commission on Law & Aging. The ABA will waive the $125 registration fee for lawyers who agree to provide pro bono services through a local SHIP. We urge state SHIP directors who want to participate in this program to respond to a brief questionnaire on HAP’s Medicare page.

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