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Archive
Weekly Email: Week of September 4, 2006
I. Conference Call Information
Next Medicare Conference Call on September 20
II. In the News
CMS Addresses Mistaken Part D Premium Refunds
KFF Reports on SHIP Focus Group Discussion about Part D Experiences
KFF Releases Report on Part D’s Role for People with HIV/AIDS
III. Helpful Information
NSCLC Announces Two New Medicare Part D Resources
CMS Clarifies Part D Complaint Process in New Tip Sheet
Answers to Questions on Safety Syringes, Cough and Cold Medicine Exclusion, and Unused Prescriptions
CMS Highlights New Home Health Demonstration Project
CMS Proposes Rule to Prevent Mid-year Benefit Changes to MA Plans
CMS Posts Part D Plan-Level Enrollment Data
CMS Releases Q&A on Safety Net Pharmacies Waiving Part D Costs
CMS Releases Coverage Gap Tip Sheets
IV. HAP News and Resources
HAP Staff Expands Again: Welcome Heather Bates!
Changes to HAP E-Mail Addresses and Web Domain
Families USA Annual Conference Runs from January 25 to 27, 2007
I. Conference Call Information
Next HAP Monthly Conference Call on September 20
The next HAP monthly conference call for the SHIP network and partners will be held on Wednesday, September 20, 2006 at 3:00 p.m. EDT. Using the same strategies with which we approached the first Part D enrollment period, i.e., breaking down the information, segmenting Medicare populations and following the timeline set by the Medicare Modernization Act, we will engage in an interactive discussion of the work-planning challenges for SHIPs and their partners. Please contact Hilary Dalin at hdalin@hapnetwork.org with your questions, comments and suggestions for this call.
II. In the News
McClellan Announces His Resignation
On September 5th, Mark McClellan formally announced his plans to resign as head of the Centers for Medicare and Medicaid Services (CMS). McClellan has served in four health policy positions under both the Bush and Clinton Administrations. As CMS Administrator he directed implementation of the Medicare Prescription Drug benefit as part of the Medicare Modernization Act. He is expected to officially leave his post in early October. For more details, please see the Washington Post article.
CMS Addresses Mistaken Part D Premium Refunds
In early August, a Centers for Medicare & Medicaid Services (CMS) data processing error led to mistaken refunds of Part D drug plan premiums to more than 230,000 Medicare beneficiaries. The refunds came as checks from Social Security or as direct deposits to checking accounts. CMS reported that the mistake affected beneficiaries in all states and the territories, but did not involve any beneficiaries receiving the low-income subsidy, or extra help. The refunds averaged $215.
After it caught the mistake, CMS sent a letter on August 18 to the 230,000 affected beneficiaries. The letter assured them that they still have Medicare drug coverage, instructed them to save the extra payment, and put them on notice they will be asked to return the money to the government with details to follow.
On August 29, CMS announced that it is sending a second letter to the affected beneficiaries to explain their options and procedures for returning the mistaken refunds to CMS. At the same time, CMS issued a “Premium Withhold Refund Issue Tip Sheet” for its community-based partners. The letter and tip sheet directs those who received a refund check (and who have not yet cashed it), to return the check to a Medicare post office box in Pleasanton, California with the word VOID written on its face. Beneficiaries who received refunds via direct deposit to their checking accounts can authorize an automatic debit or send a personal check or money order to Medicare.
For those who cannot repay the full refund amount in a lump sum, Medicare directs them to a CMS toll-free number, 1-866-292-8080, to ask to pay in installments over a period of up to seven months. Note that this number is a dedicated CMS phone line, separate from the 1-800-MEDICARE call center number. When HAP tested the phone line on August 30, a CMS representative in Texas answered the call within two rings. CMS also stressed in its letters and tip sheet that regular premium withholding will resume in October, with premiums for two months withheld from October Social Security benefits.
CMS’s refund error concerned some on Capitol Hill. Senator Chuck Grassley (R-Iowa), one of the principal authors of the Medicare Part D legislation, sent a letter on August 23 to CMS Administrator Mark McClellan. Grassley wrote that, “I am very troubled by your recent announcement that a computer error caused a number of beneficiaries to erroneously receive refunds of their Medicare Part D premiums that must now be recovered from them.” Grassley urged CMS to recover the mistaken refunds in increments over as long a period as possible, and asked the Administrator to deliver a report to Congress by September 6, 2006, to detail how the error occurred.
HAP will follow developments on this issue, and report on them in upcoming editions of the HAP Email Update.
KFF Reports on SHIP Focus Group Discussion about Part D Experiences
The Kaiser Family Foundation (KFF) on August 24 released a report about the challenges that Medicare beneficiaries have faced in the early stages of the Part D program’s implementation. The report is based on a focus group discussion with representatives of thirteen state SHIP programs, most of them state Directors, that took place on June 27, 2006 at the annual SHIP Directors Conference in Denver, Colorado.
Among its key findings, KFF said that all of the participants reported that their programs had experienced significant casework related to plan enrollment resulting from data system errors, time delays or systemic inadequacies. According to Kaiser, all participants agreed that the information systems of the several players--CMS, Social Security, state Medicaid agencies, and the drug plan sponsors--must be able to communicate one with the other in an accurate, timely manner.
The focus group participants also described problems involving premium payments, cost-sharing overcharges for those eligible for the extra help program, access to drugs stemming from some plans’ misuse of utilization management tools, and questionable marketing activities involving agents for Medicare Advantage plans. The SHIP Directors offered a number of suggestions for improvement, though “first and foremost,” they recommended “simplifying and standardizing Part D in order to help beneficiaries and their caregivers navigate the program with greater ease.”
The SHIPs whose representatives participated in the KFF focus group are California, Colorado, Delaware, Florida, Georgia, Iowa, Louisiana, Maine, Michigan, Minnesota, New Jersey, Pennsylvania and Tennessee.
KFF Releases Report on Part D’s Role for People with HIV/AIDS
Earlier in August, the Kaiser Family Foundation released another Medicare-related report entitled “The Role of Part D for People with HIV/AIDS: Coverage and Cost of Antiretrovirals Under Medicare Drug Plans”. The report, dated August 3, details the coverage and costs of antiretroviral (ARVs) under Medicare prescription drug plans for beneficiaries living with HIV/AIDS who are not low-income subsidy recipients. Kaiser used data from the Medicare Prescription Drug Plan Finder on the Medicare website during the week of May 22, 2006, to assess and analyze plan coverage for approved ARVs and ARV treatment regimens for people with HIV/AIDS.
This report’s key findings have major implications for Medicare beneficiaries with HIV/AIDS, their caregivers, and the program staff that help them. Consistent with CMS formulary guidelines, KFF found that all Medicare stand-alone prescription drug plans (PDPs) cover each of the twenty-nine drugs approved for treating people living with HIV/AIDS. Forty-seven of these PDPs, however, will not cover brand-name drugs if generic equivalents are available. It is also important to note that there is extreme variation by plan in terms of tier placement, cost-sharing, initial benefit period costs, the doughnut hole, and in the catastrophic coverage period.
Given the high costs of ARV treatments, those beneficiaries without supplemental assistance will likely reach the donut hole fairly quickly and face tremendous out-of-pocket costs before reaching the catastrophic benefit. Beneficiaries with HIV/AIDS also need to consider the coverage of their non-ARV drugs. However, PDPs that offer the best ARV drug coverage may not always provide coverage for essential non-ARV drugs. Many in this segment of the Medicare beneficiary population will face difficult decisions when weighing their options and choosing a PDP. Because of the enormity of these decisions, SHIPs should be mindful of these individuals when planning outreach and counseling activities.
III. Helpful Information
NSCLC Announces Two New Medicare Part D Resources
The National Senior Citizens Law Center (NSCLC) announced on August 25 that it has two new resources available that may be helpful to SHIP counseling and assistance staff. The first, entitled “Medicare Part D Exceptions and Appeals: A Practical Guide,” contains sections on off-label drug use, dosing exceptions, step therapy and other appeal situations that include both substantive information resources and practical advocacy tips. The second resource is a chart that highlights the differences between stand-alone PDPs and Medicare Advantage plans with Part D prescription drug coverage (MA-PD) as to eligibility, enrollment periods, enrollment choices and auto and facilitated enrollment procedures.
CMS Clarifies Part D Complaint Process in New Tip Sheet
CMS on August 24 issued Tip Sheet for partners on “Handling Medicare Part D Prescription Drug Plan Complaints.” CMS explains that Part D drug plan members should first direct their complaints to the drug plan, not to CMS. The Tip Sheet outlines a six step process for helping beneficiaries make, or follow up on, complaints (also called “grievances”). The Tip Sheet assures that “the fastest way to get an issue resolved is to contact the plan.” CMS says that it requires the drug plans to resolve complaints “as quickly as the beneficiary’s health condition requires, but no later than 30 days after receiving the complaint unless extended by the plan for an additional 14 days.” Plans must respond to complaints arising from a plan’s refusal to grant an expedited determination or redetermination within 24 hours. The Tip Sheet instructs complainants to contact CMS through 1-800-MEDICARE when plans fail to resolve complaints in a “timely manner.” If a plan still does not resolve a complaint after it works its way through CMS’s Complaint Tracking Module (CTM), then as a last resort, CMS instructs beneficiaries and their helpers to contact the CMS Regional Office (RO) via special e-mail addresses for Part D complaints. The Tip Sheet contains a list of the RO e-mail addresses, although it mentions only two examples of a grievance, namely a plan’s refusal to grant either an expedited determination or expedited redetermination request.
Answers to Questions on Safety Syringes, Cough and Cold Medicine Exclusion, and Unused Prescriptions
Cynthia Tudor, Director of CMS’s Medicare Drug Benefit Group, sent a Memorandum on August 21 to all drug plan sponsors in which she answered three Part D coverage issue questions. With respect to safety syringes used to administer insulin in long-term care facilities, she wrote, “We are correcting our previous Q&A to define insulin syringes equipped with a safe needle device, in their entirety (syringe and device) as Part D drugs and subsequently they should be managed like any other Part D drug the plan places on their formulary.”
A second discussion clarified CMS policy on the Part D exclusion for cough and cold medications. Ms. Tudor wrote that the statutory exclusion of cough and cold medications does not extend to all clinical indications for those drugs. She explained that CMS believes that Congress recognized that there are clinical circumstances where cough and cold medications are needed to treat other illnesses or injuries. As examples, she offered a case where a patient with severe osteoporosis might need these drugs to reduce the risk of broken bones from coughing might create, and where a patient with asthma might need cough medicines to minimize shortness of breath. Ms. Tudor summarized saying that, “prescription cough and cold medications are eligible to meet the definition of a Part D drug in clinically relevant situations other than the symptomatic relief of cough and colds.”
A third question asked if beneficiaries can donate unused drugs to state agencies or charitable organizations. Ms. Tudor answered, “Yes.” After Part D pays for a medication and a beneficiary takes possession of it, “the beneficiary is the owner of the medication and can dispose of the medication as they [sic] deem necessary.” This Q&A has important cost-saving implications for beneficiaries who reside in long-term care facilities that use specially-packaged drugs.
CMS Highlights New Home Health Demonstration Project
CMS on August 25 circulated on its SHIP Listserv a news release dated April 19, 2006 that announced a demonstration project that has major implications for the future of Medicare home health benefits. Medicare will cover medical adult day care services in addition to regular home health services for up to 15,000 beneficiaries who are eligible to participate. Participation is voluntary. The three year demonstration will enable CMS, according to Administrator Mark McClellan, “to assess whether providing medical adult day care services as part of the home health benefit will improve patient outcomes and increase patient satisfaction.” There are no additional out-of-pocket costs for participants who receive adult day care services through the project. CMS is working on the demonstration with five home health agencies based in Milwaukee, Wisconsin; McAllen, Texas; Allison Park (suburban Pittsburgh), Pennsylvania; Brooklyn, New York; and St. Petersburg, Florida. The project was to start in June 2006.
CMS Proposes Rule to Prevent Mid-year Benefit Changes to MA Plans
CMS issued a proposed rule in the September 1 edition of the Federal Register that would prohibit Medicare Advantage (MA) plans from making so-called Mid-year Benefit Enhancements (MYBE). The rule proposes to stop MA plans from making mid-year changes to their non-drug benefits, premiums and cost-sharing amounts after CMS has approved their annual contracts through its new competitive bidding process. Some MA plans have reduced their plan premiums and cost-sharing amounts during the contract year. CMS wrote that continuing this practice “would threaten the integrity of the competitive bidding process established by the MMA.” The deadline for comments on the proposed rule is October 31, 2006.
CMS Postings
CMS Posts Part D Plan-Level Enrollment Data
On August 1, CMS posted plan-level enrollment data for Medicare Advantage (MA), Cost, PACE, demonstration, and prescription rug plans to its website. This data will be posted during the month following the ending of the MA open enrollment period. For now, expect the next round of plan-level enrollment data in June 2007. Enrollment data at the contract level is available all other months of the year. Please see the annual report by plan for more details.
CMS Releases Q&A on Safety Net Pharmacies Waiving Part D Costs
On August 8, CMS released a Q&A fact sheet dealing with the issue of safety net pharmacies and cost-sharing. The question posed asks if safety net pharmacies may waive beneficiary cost-sharing under part D as they were previously permitted to do when dealing with financially needy individuals. The answer states that CMS allows pharmacies to waive or reduce cost-sharing amounts as long as financial need is verified and it is done in an "unadvertised, non-routine manner." For low-income subsidy recipients, pharmacies may waive or reduce cost-sharing costs routinely, but still may not advertise this. These waivers or cost-sharing reductions do indeed count towards a beneficiary's TrOOP.
CMS Releases Coverage Gap Tip Sheets
On August 14, CMS released two tip sheets having to do with the coverage gap, also known as the "doughnut hole." One of the tip sheets, is geared towards partners, like SHIPs, who work with Medicare beneficiaries. It includes basic questions and answers which address many coverage gap issues, such as how the coverage gap works and how the plans track out-of-pocket expenses. The other tip sheet is for Medicare beneficiaries. It focuses on tips an individual may use to avoid or delay entering the coverage gap, how to save money while in the gap, and information on Patient Assistance Programs (PAPs). Also available for SHIP counselors and related professionals, is a reference chart of PAPs compiled by RxAssist, a private organization.
IV. HAP News
HAP Staff Expands Again: Welcome Heather Bates!
HAP is pleased to announce that Heather Bates joined our staff in mid-August. She will work with Hilary Dalin and Kelly Brantley in HAP’s Counseling and Education Development department as a Senior Research and Training Associate. Heather brings a wealth of experience gained through her work as the Program Coordinator with the New York City HICAP Program at the New York City Department for the Aging. You can contact Heather at hbates@hapnetwork.org.
Changes to HAP E-Mail Addresses and Web Domain
Being mindful that HAP’s long-standing email addresses and web domain could be a mouthful (and then some), we are happy to report that our Information Technology (IT) staff has created a new, condensed, tag line for reaching us via the internet. Our new e-mail addresses refer to “@hapnetwork.org.” This saves correspondents from typing sixteen letters when compared with our old addresses! For example, the address for Ellen Leitzer, HAP’s Executive Director, now is eleitzer@hapnetwork.org.
In the next few weeks, we will be changing the URL for our web-site from the current www.hapnetwork.org to www.hapnetwork.org. We’ll let you know when it’s official, but want to give a “heads up” to alert those of you have links to HAP’s website on your “favorite places” lists.
Families USA Annual Conference Runs from January 25 to 27, 2007
We invite you to attend the upcoming Families USA conference set for Thursday through Saturday, January 25 to 27, 2007. HAP staffers will deliver a number of skills-building workshops that will be of interest to SHIP staff and other advocates for Medicare beneficiaries. For more information about the conference and details on registration, please see the conference website. |
