SHIIP helps NC Medicare recipients affected by Aetna sanctions | citizen-times.com | Asheville Citizen-Times

Insurance Commissioner Wayne Goodwin today announced that the Department’s SHIIP program is available to help some 23,000 N.C. Medicare recipients who may be affected by Medicare’s sanction and suspension of Aetna Insurance Company’s marketing and enrollment of its Part D prescription drug plans. The sanction will remain in effect until the company demonstrates that it has corrected the cited problems. Although the sanction does not impact current Aetna Part D members, if they are experiencing difficulties in getting their prescriptions SHIIP is here to help.

“North Carolina has more than 23,000 Medicare recipients enrolled in Aetna Part D plans, and I want those folks to know that if they’ve had delays getting their prescriptions filled, our SHIIP program can help,” said Commissioner Goodwin. “We don’t anticipate recipients having too much trouble – and remember their current coverage is not impacted – but if someone has a Medicare Part D plan with Aetna, and they’re having problems they should call our SHIIP helpline at 1-800-443-9354.”

Medicare issued the intermediate sanction because the plan has failed to fully meet its obligations to Medicare beneficiaries.

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H.R. 3799: To amend title XVIII of the Social Security Act to improve prescription drug coverage under... (GovTrack.us)

To amend title XVIII of the Social Security Act to improve prescription drug coverage under Medicare part D and to amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986, to improve prescription drug coverage under private health insurance, and for other purposes.

Sponsor: Rep. Henry Johnson [D-GA4]
Cosponsors: Russ Carnahan [D-MO3], Lloyd Doggett [D-TX25], Keith Ellison [D-MN5], Marcia Fudge [D-OH11], Patrick Kennedy [D-RI1], Mary Jo Kilroy [D-OH15], Barbara Lee [D-CA9], Timothy Ryan [D-OH17]

Text

Status:
Introduced Oct 13, 2009
Referred to Education and Labor Committee

Updated Information

H.R. 3806: To amend the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to extend and... (GovTrack.us)

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To amend the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to extend and expand the Medicare rural community hospital demonstration program.

Sponsor: Rep. Jerry Moran [R-KS1]
Cosponsors:

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Status:
Introduced Oct 14, 2009
Referred to Committee on Ways and Means

Updated Information

MEDICARE PART D RECONCILIATION PAYMENTS FOR 2006 AND 2007

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The DHHS Office of Inspector General found that Part D sponsors owe a net total of $18 million to Medicare
for the 2007 Part D payment reconciliation, which is significantly less
than the net total of $4.4 billion that sponsors owed for 2006. Despite
this improvement, sponsors continue to submit inaccurate bids and make
large unexpected profits.

CMS makes monthly prospective payments to sponsors for providing
prescription drug coverage to Medicare beneficiaries. These payments
are based on estimates that sponsors provide in their bids prior to the
beginning of the plan year. After the close of the plan year, CMS
reconciles these payments with the sponsors' actual costs to determine
whether sponsors owe money to Medicare or Medicare owes money to
sponsors.

More specifically, sponsors owe Medicare a net total of $600 million
because of unexpected profits or losses that triggered risk sharing for
2007. Many of these sponsors overestimated the costs of providing the
benefit in their bids. As a result, Medicare payments to sponsors and
beneficiary premiums were higher than necessary. Medicare recoups a
portion of these higher payments. However, beneficiaries do not
directly recoup any of the money that they paid in higher premiums. At
the same time, sponsors will receive a net total of $406 million from
Medicare for the low-income cost-sharing subsidy and a net total of $186
million for the reinsurance subsidy because they underestimated these
costs in their bids.

Further, sponsors continue to make large unexpected profits. Based on
OIG calculations, the 179 sponsors that had profits large enough to
trigger risk sharing made at least $1.02 billion in unexpected profits
in 2007. These sponsors owe a portion of these unexpected profits to
Medicare based on the risk-sharing requirements. In addition, sponsors
included an estimated $1.07 billion of expected profits in their bids.

Finally, for 2006, CMS collected almost all of the funds that sponsors
owed to Medicare in November and December 2007. However, CMS has not
collected a total of $14 million from five sponsors for 2006.

Based on these findings, OIG recommends that CMS should: (1) ensure that
sponsors' bids more accurately reflect their costs of providing the
benefit to Medicare beneficiaries, (2) hold sponsors more accountable
for inaccuracies in the bids, (3) determine whether changes to the risk
corridors are appropriate, (4) determine whether alternative
methodologies would better align payments with sponsors' costs for the
low-income cost-sharing and reinsurance subsidies, and (5) follow up
with the sponsors that owe funds for 2006. CMS concurred or agreed with
three of the recommendations but did not state whether it concurred with
OIG's second or third recommendations.

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S. 1634: Medicare Prescription Drug Coverage Improvement Act (GovTrack.us)

A bill to amend titles XVIII and XIX of the Social Security Act to protect and improve the benefits provided to dual eligible individuals under the Medicare and Medicaid programs.

Sponsor:
Sen. John Rockefeller [D-WV]
Cosponsors:
Daniel Akaka [D-HI]
Mark Begich [D-AK]
Sherrod Brown [D-OH]

Text: Full Text

Status:
Introduced Aug 6, 2009

Referred to Committee on Finance


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S. 1630: Affordable Access to Prescription Medications Act of 2009 (GovTrack.us)

A bill to amend title XVIII of the Social Security Act of improve prescription drug coverage under Medicare part D and to amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to improve prescription drug coverage under private health insurance, and for other purposes.

Sponsor:Sen. John Rockefeller [D-WV]
Cosponsors:Al Franken [D-MN]

Text:Full Text

Introduced Aug 6, 2009

Referred to Committee on Finance

Medicare Part D Drug Benefit Donut Hole, Proposed Changes - Health Blog - WSJ

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By Jacob Goldstein

The gurus over at the nonpartisan Congressional Budget Office just ran the numbers on proposed changes to Medicare Part D under HR 3200, the big health care bill from House Democrats. The conclusion: If the bill were to become law (a big if at this point), seniors’ average total spending on prescription drugs would decrease, but their premiums would rise.
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Medicare Part D premiums to inch up in 2010

By Chris Silva, AMNews staff Most beneficiaries shouldn't see a significant change in premium costs for drug coverage, but some low-income subsidy recipients might need to switch plans.

Examining Sources of Coverage Among Medicare Beneficiaries: Supplemental Insurance, Medicare Advantage, and Prescription Drug Coverage -- Findings from the Medicare Current Beneficiary Survey, 2006 - Kaiser Family Foundation

This updated chartpack presents sources of supplemental and prescription drug coverage among Medicare beneficiaries in 2007, the most recent year for which national data are available. The chartpack looks at variations in supplemental and prescription drug coverage by income, race/ethnicity, age, urban/rural location, and health status. It also examines characteristics of Medicare beneficiaries with low incomes who are not enrolled in a Part D plan or receiving Part D low-income subsidies. Prepared by Kaiser Family Foundation researchers, the chartpack is based on analysis of the 2007 Medicare Current Beneficiary Survey. Download Chartpack

Close the Doughnut Hole

Asclepios - Your Weekly Medicare Consumer Advocacy Update from the Medicare Rights Center Medicare’s Part D drug benefit has a built-in gap in coverage known as the “doughnut hole,” when coverage stops and consumers must pay the full cost for their medicine. The doughnut hole exists because the high cost of drugs made it too expensive for Congress to provide continuous drug coverage—the kind of drug coverage most Americans have through their employer-sponsored health plans. People with limited incomes can get coverage during the gap through a federal program called Extra Help, but for people with incomes or assets too high to qualify for this program, the effects of the gap on their health can be devastating. Here is what the studies show: * 3.4 million people with Medicare fall into the doughnut hole. * Over one-third of people with diabetes and hypertension fall into the gap. * Over 60 percent of people with diabetes, hypertension, congestive heart failure and high cholesterol fall into the gap. * Many people who fall into the gap skip doses or stop filling all their prescriptions, reducing their drug use on average by 14 percent. * Use of both generic and brand-name medicines to prevent blood clots drops sharply once people hit the gap, and continues dropping with each month they are in the doughnut hole. * One in ten people taking medicine to control diabetes stop taking their drugs when they hit the gap. The statistics are grim, but there is hope. Health reform legislation—HR 3200, America’s Affordable Health Choices Act of 2009—now making its way through the House of Representatives would phase out the Part D doughnut hole. The bill requires price concessions from drug manufacturers and uses the savings to help Medicare gradually narrow the coverage gap until, in 2023, it disappears completely. For the short term, the legislation also requires brand-name drug manufacturers to provide a 50 percent discount to people who fall into the doughnut hole, the result of a deal reached with drug makers, the White House and the Senate Finance Committee. Together, both provisions result in savings to Medicare of nearly $30 billion over ten years. Health reform legislation that passes Congress must include a plan to fully close the doughnut hole. Please write your senators and representatives and remind them to Remember People with Medicare in health reform and close the doughnut hole when they pass health reform.

Medical News: Still More Questions than Answers on Impact of Medicare Drug Benefit - in Public Health & Policy, Medicare from MedPage Today

By John Gever, Senior Editor, MedPage Today Preliminary indications are that Medicare Part D has improved seniors' access to prescription drugs at lower-than-expected cost to taxpayers, but problems and questions still remain, according to a review from the Kaiser Family Foundation. One of the biggest problems is the "doughnut hole," the coverage gap in Part D that forces Medicare beneficiaries to pay all drug costs between $2,700 and $6,154, according to Patricia Neuman, ScD, and Juliette Cubanski, PhD, of Kaiser. Published in the July 23 issue of the New England Journal of Medicine, their report found that, since Part D went into effect, nonadherence to prescribed medications because of cost has decreased -- except among patients falling into the doughnut hole. Read More

NEJM -- Medicare Part D Update -- Lessons Learned and Unfinished Business

Patricia Neuman, Sc.D., and Juliette Cubanski, Ph.D. Since 2006, more than 40 million elderly and disabled people have had the opportunity to enroll in a Medicare Part D prescription-drug plan, as established under the Medicare Modernization Act (MMA) of 2003. Members of Congress, deeply divided by policy and ideological differences, debated several features of the proposed legislation before its passage.1 Issues that received particular scrutiny were the unprecedented way that the benefit would be delivered (exclusively through private plans) and its design, featuring an unusual gap in coverage (sometimes called the "doughnut hole"). Policymakers questioned whether insurance companies would be willing to offer stand-alone drug plans, how many beneficiaries would choose to enroll in a voluntary program, and how the program would affect drug prices and overall Medicare spending.2 With the fourth year of Medicare Part D under way, the Obama administration and the Democratically controlled Congress have an opportunity to review the program and identify areas for improvement. In this article, we return to several key questions raised during the 2003 congressional debate and in the years leading up to the start of the program. We review evidence that has accumulated since the benefit launched in 2006 and discuss issues that may emerge on the policy agenda. Read More

Strategies for Simplifying the Medicare Advantage Market - Kaiser Family Foundation

Most Medicare beneficiaries have at least 40 Medicare Advantage (MA) plan options to choose from this year. While some favor a robust marketplace, others argue that fewer plan offerings, or more transparent differences across plans designs, would help beneficiaries choose plans most likely to meet their individual needs. While consumers generally show interest in choice and economists see it as enhancing value, research shows that individuals faced with a large number of alternatives often avoid making a decision or choose options that may not be the best for them economically. This report prepared for the Kaiser Family Foundation presents new data on Medicare Advantage plans, and uses these data to examine a range of policy options that would simplify choices for Medicare beneficiaries, including changes recently proposed by the Obama Administration. This paper assesses the implications for beneficiaries and the potential change in the number of plan offerings as a result of each option. It was authored by Marsha Gold of Mathematica Policy Research. Full Report

CMS: Medicare Advantage Data Collection

1. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Medicare Advantage and Prescription Drug Program: Final Marketing Provisions CFR 422.111(a)(3) and 423.128(a)(3) Use: Medicare Advantage (MA) plans must provide notice to plan members of impending changes to plan benefits, premiums and copays in the coming year so that members will be in the best position to make an informed choice on continued enrollment or disenrollment from that plan at least 15 days before the Annual Election Period (AEP). Beginning 2009, organizations will be required to notify plan members of the coming year changes using a combined standardized document at the time of enrollment and annually thereafter.

H.R. 3152: To amend titles XVIII of the Social Security Act to ensure that low-income beneficiaries have... (GovTrack.us)

To amend titles XVIII of the Social Security Act to ensure that low-income beneficiaries have improved access to prescription drugs under the Medicare and Medicaid programs. Sponsor: Rep. Rush Holt [D-NJ12] Cosponsors [as of 2009-07-10] Rep. Lloyd Doggett [D-TX25] Text: The text of this legislation is not yet available on GovTrack. It may not have been made available by the Government Printing Office yet. Status: Introduced Jul 9, 2009 Referred to House Ways & Means Committee H.R. 3152: To amend titles XVIII of the Social Security Act to ensure that low-income beneficiaries have... (GovTrack.us) Shared via AddThis

SSA: Revision of Medicare Part D Forms

Request for Comments The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. Therefore, your comments would be most helpful if you submit them to SSA within 60 days from the date of this publication. Individuals can obtain copies of these collection instruments by calling the SSA Reports Clearance Officer at 410-965-0454 or by writing to the e-mail address listed above. 1. Application for EXTRA Help with Medicare Prescription Drug Plan Costs--20 CFR 418.3101--0960-0696. The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and provided for certain subsidies for eligible Medicare beneficiaries to help pay for the costs of prescription drugs. SSA uses Form SSA-1020 (and the i1020, its electronic counterpart), the Application for Extra Help with Medicare Prescription Drug Plan Costs, to collect information to make Part D subsidy eligibility determinations. In compliance with Public Law 110-275, beginning in January 2010, SSA will use a new version of Form SSA-1020. In this new version, SSA will eliminate questions about the value of life insurance policies and in-kind support and maintenance, and we will ask applicants about their interest in applying for the Medicare Savings Program. This information collection request (ICR) is for the new version we will use in 2010. The respondents are Medicare beneficiaries who are applying for the Medicare Part D subsidy. 2. Medicare Subsidy Quality Review Forms--20 CFR 418(b)(5)--0960-0707. The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and provided for certain subsidies for eligible Medicare beneficiaries to help pay for the costs of prescription drugs. As part of its stewardship duties of the Medicare Part D subsidy program, SSA must conduct periodic quality review checks of the information Medicare beneficiaries report on their subsidy applications (Form SSA-1020). SSA uses the Medicare Quality Review program to conduct these checks. Beginning in January 2010, SSA will revise the Medicare Quality Review system to comply with Public Law 110-275. Specifically, we will: (1) Eliminate the use of Form SSA-9309, the Life Insurance Verification form; and (2) remove any questions about life insurance policy values and in-kind support and maintenance from the other forms in the collection. This ICR is for the revised Medicare Quality Review System, which we will not use until January 2010. The respondents are applicants for the Medicare Part D subsidy whom we have chosen to undergo a Quality Review. 3. Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs--0960-0723. As required by the Medicare Modernization Act of 2003 (Pub. L. 108-173), SSA conducts low-income subsidy eligibility redeterminations for Medicare beneficiaries who filed for the subsidy and were determined by SSA to be eligible. SSA will conduct subsidy eligibility redeterminations under two circumstances: (1) When an individual completes Form SSA-1026-OCR-SM-SCE to report a subsidy-changing event (marriage, separation from a spouse, separated spouses resume living together, divorce, annulment, or death); and (2) When SSA uses Form SSA-1026-OCR-SM-REDE to conduct an annual review of individuals who became entitled during the prior 12 months, an annual review of a percentage of individuals who are eligible for more than 12 months, and a review of individuals who report a change in income, resources, or household size that may affect the subsidy amount. In compliance with Public Law 110-275, SSA will use a new version of Form SSA-1026 beginning in January 2010. In this new version, SSA will eliminate questions about the value of life insurance policies and in-kind support and maintenance. The respondents are current recipients of the Medicare Part D low-income subsidy who will undergo an eligibility redetermination for one of the reasons mentioned above.

A Hidden Cost in Medicare Drug Benefit: ‘Reference-Based Pricing’

Posted by Jacob Goldstein in the Wall Street Journal Health blog Seniors who insist on getting a brand-name drug when a generic version is available may wind up paying a high price. That seems fair enough: Why should the Medicare drug benefit pay extra because someone refuses to take a generic? The problem, this morning’s WSJ suggests, is a lack of transparency that may leave seniors unaware they’ll be on the hook for the higher price of the branded drug. “I am concerned that beneficiaries could find themselves paying far more out-of pocket than they expected,” Rep. Pete Stark (D., Calif.) recently wrote in a letter to the Centers for Medicare and Medicaid Services. Today, the AARP is going to issue a warning to seniors and send a letter to CMS complaining about the lack of disclosure around the practice, known as reference-based pricing.

CMS Medicare Prescription Drug Benefit Manual

CMS has published online its Medicare Prescription Drug Benefit Manual. Table of Contents Chapter 1 - Introduction and General Provisions (v09.26.08) [PDF, 97KB] Chapter 2 - Part C and D Marketing Guidelines (v07.25.06) [PDF, 838KB] Chapter 4 - Creditable Coverage Period Determinations/Late Enrollment Penalty (v06.27.06) [PDF, 210KB] Chapter 5 - Benefits and Beneficiary Protections (v07.03.08) [PDF, 629KB] Chapter 6 - Part D Drugs and Formulary Requirements (v07.18.08) [PDF, 901KB] Chapter 7 - Quality Improvement and Medication Therapy Management (v09.15.08) [PDF, 173KB] Chapter 9 - Fraud, Waste and Abuse (v04.25.06) [PDF, 543KB] Chapter 12 - Employer/Union Sponsored Group Health Plans (v11.10.08) [PDF, 278KB] Chapter 13 - Premium and Cost-Sharing Subsidies for Low-Income Individuals (v11.21.08) [PDF, 406KB] Chapter 14 - Coordination of Benefits Guidelines (v.09.26.08) [PDF, 742KB] Related Links Inside CMS Chapter 3 - PDP Enrollment and Disenrollment Guidance [PDF, 250KB] Chapter 18 - Part D Enrollee Grievances (v01.01.08) [PDF, 305KB]

GAO Report: Medicare Part D Information & Annual Election Period

What GAO Found: Sponsors, pharmacists, beneficiary advocates, and counselors GAO interviewed expressed concern that CMS’s model ANOC for the 2008 AEP did not effectively communicate drug plan changes to enrollees. They noted that it contained language at a reading level too high for some beneficiaries as well as too much, often irrelevant, information. To help ensure their enrollees understood how plan changes would affect them personally, two study sponsors mailed additional information detailing specific changes in coverage and costs for drugs the beneficiary took in the past year. Despite GAO’s previous recommendation that CMS ensure that its Part D materials meet communications guidelines, CMS’s process for developing its model ANOC did not include a systematic evaluation of its effectiveness. However, CMS officials reported that they recently initiated an evaluation of their annual Medicare beneficiary materials for the 2010 AEP that will examine reading levels, effectiveness, and length, among other factors. Such an evaluation is important in light of changes CMS has made for the 2009 AEP, which have raised further concerns among stakeholders. It is unclear whether alternative formats for communicating plan changes to beneficiaries will be considered. Although CMS and plan sponsors made improvements to the enrollment process, CMS data showed that about 15 percent of beneficiaries who chose to switch plans in the 2008 AEP were not fully enrolled in their new plan by January 1. Modifications to the enrollment process for the 2008 AEP reduced the time needed to enroll beneficiaries in a new plan to a median of 5 days. However, the volume of applications submitted late in the AEP contributed to beneficiaries being at risk of not having access to their new coverage by January 1. In fact, among the beneficiaries who submitted applications after December 15, 40 percent were not completely processed until after the effective date of their new coverage. As a result, stakeholders reported that beneficiaries, pharmacies, and sponsors faced various operational challenges, including the risk of inaccurate charges and additional administrative burden. Some stakeholders we interviewed for our study said that creating an interval for enrollment processing between the end of the AEP and the effective date of coverage would help ensure that beneficiaries switching plans would have their coverage in place on January 1. What GAO Recommends To improve the AEP, GAO recommends that CMS strengthen its evaluation of its model materials by reviewing alternative formats to communicate plan changes. Additionally, Congress should consider authorizing the Secretary of Health and Human Services to amend the AEP schedule to include a processing interval between the end of the AEP and the effective date of new coverage. In commenting on our draft, CMS stated that it concurs with our recommendation and will consider reviewing other ANOC formats.

Medicare Part D Enrollment Counseling & Plan Formulary-Cost Variations

Part D Enrollment Counseling and Plan Formulary-Cost Variations


Benefits counselors are noticing some very complicated options some Part D plans are using in 2009 to encourage greater use of generics. It’s important to understand these variations for effective Part D enrollment counseling. Learn more here in an attachment to the article on Types of Part D Plans in the About the Part D library. You can also read the CMS Prescription Drug Manual provisions that plans follow when they use these options.

New CMS Plamphlet

CMS has published a new consumer tip sheet describing the documents that are Best Available Evidence to prove Extra Help Satus and establish the correct level of Extra Help copayment.