The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “CMS”

09 Nov 2012

Medicare Extends Open Enrollment Period For People Affected By Sandy

Breaking News for Hurricane Sandy and MedicareI just got some good news from The Medicare News Group for Medicare beneficiaries who are still coping with damage from Hurricane Sandy in the northeast:

The Centers for Medicare & Medicaid Services (CMS) has extended the December 7 deadline to enroll in a private medical or prescription drug plan for next year if you have been affected by Hurricane Sandy.

According to CMS, beneficiaries hit by the storm can still enroll after the midnight Dec. 7 deadline if they call Medicare’s 24-hour information line,1-800-Medicare (1-800-633-4227).  Representatives will be able to review available plans and complete the enrollment process with them over the phone. Medicare officials have not set a new deadline but are encouraging beneficiaries to make their decisions soon if possible.

The opportunity to enroll in a plan after Open Enrollment ends on December 7 applies to everyone affected by Hurricane Sandy, including those who do not live in the affected areas but rely on help making healthcare decisions from friends or family members who do live in the affected areas.

“This is a really important recognition by CMS to accommodate Medicare enrollees affected by Hurricane Sandy,” said Leslie Fried, director for policy and programs at the National Council on Aging, a Washington, D.C., advocacy group.  I wholeheartedly agree.

 

Posted in Medicare Part D Open Enrollment and tagged , , , | Leave a Comment
16 Oct 2012

Why Medicare star ratings are important to you during Open Enrollment

Medicare Plan Star RatingsGiven the choice of staying in a 2-star hotel in a seedy neighborhood for $60 a night or a 4-star hotel near the ocean for $100 a night, I’m going to opt for the 4-star hotel. Even though it will cost me more, I know that the higher star rating will mean I’m getting a higher-quality room, better service, and more value for my vacation dollars. I may even get an indoor pool, hot tub, and gym, which right away makes it worth paying $40 more.

The same is true for Medicare coverage. I would never recommend a Medicare Part D or Medicare Advantage plan with a low star rating to a friend or loved one. Low star ratings in Medicare mean lower quality. And lower quality often means less value, poor customer service, and less customer satisfaction.

Each year, the Centers for Medicare & Medicaid Services (CMS) rates how well health plans and prescription drug plans perform in different categories, such as customer service, prescription drug safety, and member satisfaction. The Medicare star ratings are important because they help you compare the overall quality of plans during Medicare Open Enrollment. Star ratings range from 1 star (poor performance) to 5 stars (excellent performance), so look for a plan with high ratings (4 or 5) to ensure you get the level of service and safety you deserve.

Use the following resources to get Medicare plan star ratings:
• The overall plan star ratings are available at the Medicare Plan Finder.   
• You can call 1-800-MEDICARE (1-800-633-4227). TTY users: 1-877-486-2048.
• You can call your plan’s customer service number and ask for the plan’s Medicare
   star rating.

More high-quality Medicare plan choices in 2013
According to Health and Human Services Secretary Kathleen Sebelius, more 4- and 5-star plans will be available in 2013 than ever before.
In 2013:
• People with Medicare will have access to 127 four- or five-star Medicare Advantage plans. In 2012, people with Medicare had access to only 106 four- or five-star plans, which served only 28 percent of enrollees.
• People with Medicare will have access to 26 four- or five-star prescription drug plans, which currently serve 18 percent of enrollees. This is an improvement from 2012, in which only 13 plans with four or five stars serve just 9 percent of enrollees.

Switch to a 5-star Medicare Advantage or Part D Plan at any time during the year
If you’re fortunate enough to find a 5-star plan that serves your area and meets your health and budget needs, you can enroll in that plan any one time during the year, starting as early as December 8, 2012.

Posted in Medicare Part D Open Enrollment and tagged , , , , , | Leave a Comment
14 Aug 2012

This Medicare article is not about Paul Ryan or Obamacare. It’s about a new Medicare rule for power wheelchairs.

Seven states will require a prior authorization process to get Medicare coverage for power wheelchairs and scooters.

For the past few days, my inbox has been bombarded with news about the Paul Ryan budget and its projected impact—good and bad—on Medicare. I’m not a political pundit and I don’t pretend to be one, so I have no intentions of joining the Ryan-Romney-Medicare bandwagon. What I do want to talk about are the real (i.e., known) issues that are going to affect Medicare beneficiaries now or in the very near future.

Although it was like trying to find a needle in a haystack, I found such a real topic yesterday, in an article from American Medical News.  It turns out that while everyone has been worrying about Mr. Ryan and his proposed budget plans, Medicare beneficiaries in seven states are actually going to have to wait longer than beneficiaries in other states to get Medicare coverage for their power wheelchairs or scooters. This news is for real.

Beginning September 1, 2012, and continuing thereafter for the next three years, the Centers for Medicare & Medicaid Services (CMS) will require prior authorization for power mobility devices prescribed in seven states: California, Florida, Illinois, Michigan, New York, North Carolina, and Texas. CMS is calling this a “demonstration project,” which they said will allow them to collect data that will be used to combat fraudulent claims for power motility devices.
 
Under the three-year project, providers in the seven states will need to send authorization requests and supporting documentation to a Medicare contractor when ordering power wheelchairs for patients. The contractor will review the request to ensure that it meets national and local coverage requirements. Contractor approval will be necessary before patients can receive the items.  

According to CMS, the prior authorization review process will take about 10 business days. Expedited reviews will be available when a patient’s health would be harmed without access to the power wheelchair or scooter.

Medicare power wheelchair fraud has been rampant in recent years. According to CMS, federal law enforcement agencies have prosecuted more than 600 cases representing almost $3 billion in fraudulent claims since 2009. The seven states chosen for this demonstration project represent more than 40 percent of power mobility device orders through Medicare.

I’m not totally sure that a prior authorization process is the right tactic to take here, although I do give CMS credit for trying new ways to control Medicare fraud. And hey, maybe if CMS saves enough money by reducing fraud, we won’t have to talk about a Paul Ryan budget plan anymore…I’ll leave it at that.

Posted in Medicare Fraud, Power mobility devices and tagged , , , , , , | Leave a Comment
17 May 2012

The Medicare MTM Program – Part II: Just What the Doctor Ordered

MTM: Just what the doctor orderedAs I mentioned in my last post, I’ve been writing a letter that invites my company’s Part D plan members to participate in Medicare’s Medication Therapy Management (MTM) program. The main feature of the Medicare MTM program is an annual comprehensive medication review, which includes a review of all medications, vitamins, and supplements with a pharmacist; a written summary and medication action plan to share with doctors; and a personal medication list. 

The letter has been written and approved, but I still have my doubts that it is going to convince people to take advantage of this free program. For some reason—well, many reasons—seniors who take a lot of medications just don’t think they need an annual medication review, even if their health and safety is at risk.

Aging and multiple medications increase your health risks

But here’s the hard truth, plain and simple: If you take multiple medications, your chances of ending up in the hospital because of dangerous side effects or a harmful drug interaction are pretty high. To make matters worse, aging increases your risk for medication side effects.

If you take multiple medications, you’re not alone

The average older American uses 4-5 prescription drugs and 2 over-the-counter medications.  The average nursing home resident uses at least 7-8 prescription drugs.  Here are a few other facts to consider:

• The more medications you take, the more chance there is for those drugs to interact negatively with each other — or with vitamins, supplements, and even certain foods.
• You may think the symptoms of such harmful interactions are normal, such as an upset stomach or feeling tired. Or you may not notice any symptoms at all. 
• If you are taking multiple drugs, there also is a greater risk of forgetting to take medications, taking them at the wrong time, or taking too much or too little.
• The more drugs you take, the more likely at least one of those drugs is not necessary.  

The MTM comprehensive medication review is just what the doctor ordered

Let’s face it. It’s not always easy to keep track of your drugs or know how to use them safely. That’s why the Institute of Medicine encourages people to participate actively in the healthcare process to prevent medication-related problems. One of the things that doctors suggest is a medication review with a healthcare provider at least once a year.

So what are you waiting for?

I hope I have encouraged at least a few seniors to participate in their Medicare prescription drug plan’s MTM program. And I hope you say “yes” if your plan invites you to have a comprehensive medication review with a pharmacist. Your health and safety depend on it.

Posted in Medicare, Medication Therapy Management (MTM) and tagged , , , , , , | Leave a Comment
13 Apr 2012
3 Comments

Do Medicare cover Viagra for erectile dysfunction? No it do not. (But sometimes it get screwed anyway.)

Medicare Part D gets screwedOne of the ways I stay on the top of the Medicare industry is by using Google Alerts to monitor the Internet for information about Medicare benefits and regulations. Each day I receive about three or four email updates from Google Alerts, which include links to news articles, blog posts, and miscellaneous Web content.

Although the news articles and blogs are always legitimate, the links under the miscellaneous Web category are almost always spam, with such gramatically-incorrect headlines as “Do medicare cover viagra?” or “Get you cialis with Medicare.” Inevitably, the links take me to some article or advertisement that has nothing to do with either erectile dysfunction (ED) or Medicare.

Just in case anyone is still falling for this spam, Medicare does not cover ED drugs – for the most part.

According to P.L. No. 109-91, section 103, amended section 1860D-2(e)(2)(A) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Medicare Part D program does not cover ED drugs “when used for the treatment of sexual or erectile dysfunction.”  But here’s the catch (of course there’s a catch; we’re talking about Medicare): ED drugs such as Cialis®, Viagra®, and Levitra® are covered by Part D when prescribed for medically accepted indications other than sexual or erectile dysfunction (such as pulmonary hypertension).

Medicare has been screwed to the tune of $3 million

According to a March 2011 report from the Department of Health and Human Services Office of Inspector General (OIG), of approximately $133 billion in gross drug costs for the years 2007 and 2008, Medicare covered more than $3 million in drug costs for ED drugs approved for the treatment of sexual or erectile dysfunction. Part D should not have covered these drugs.

Based on the findings of the study, titled “Review of Erectile Dysfunction Drugs in the Medicare Part D Program,” the OIG recommended the Centers for Medicare & Medicaid Services (CMS) maintain a comprehensive list of ED drugs that have been approved by the FDA for the treatment of sexual or erectile dysfunction. The OIG also recommended CMS distribute this list to all Medicare Part D plan sponsors.

Although this news is two years old, so far I have yet to see this comprehensive list of ED drugs. I also haven’t seen any more reports of Medicare mistakenly covering these drugs. Hopefully this means that CMS has its act together despite the lack of a list. But then again, maybe these spammers who keep cropping up on my Google Alerts know something we don’t know.

Posted in Medicare Fraud, Medicare Part D and tagged , , , , , ,
07 Feb 2012

If pharmacy rejects your Medicare Part D drug claim, the doctor may be at fault

Starting in 2013, all prescriptions for Part D drugs will require the provider's NPI number.

Recently I learned about several Medicare beneficiaries who were not able to get their medication because their local pharmacy couldn’t process their prescriptions under Medicare Part D. Some of these members ended up paying the full cost of the drug out of pocket. A few left the pharmacy empty-handed, not knowing that the pharmacy was supposed to get some additional information from the doctor and re-process the claim.

What happened is this: The doctor’s ID on the prescription slip was either invalid, inactive, or missing altogether.  (It’s actually more complicated this, but I’m trying to keep it simple.)

Medicare currently accepts 4 types of prescriber IDs

There are four types of prescriber IDs, called identifiers, which Medicare currently accepts under the Part D program: NPI (National Provider Identifier), DEA (Drug Enforcement Administration), UPIN (Unique Physician Identification Number), and state license number. In an effort to control Medicare fraud, waste, and abuse, the Centers for Medicare & Medicaid Services (CMS) requires prescription drug plans to ensure these identifiers are active and valid before Medicare will make payment.

Currently, some prescription drug plans accept only the 10-digit NPI number. Starting in 2013, NPI will be the only prescriber identifier that CMS will accept on Part D claims. So if your prescription does not have a valid NPI, your pharmacist will have to contact your doctor in order to get this information before filling your prescription. And that could be a great inconvenience to you.

Get proactive to make sure your prescriptions go through
The bottom line is that pharmacies are required to submit valid prescriber identifiers with all Medicare Part D claims. Although doctors should be responsible enough to include this information on every prescription, from what I’ve read on several pharmacists’ blogs, this is often not the case. So you may want to be more proactive the next time you get a prescription for a Part D-covered drug: 

• Remind your doctor that his or her NPI must be reported legibly on all prescriptions.
• Make sure the doctor records his or her own NPI on the prescription, and not the NPI of a group practice, hospital, or other facility.
• If your doctor practices at a hospital and writes a prescription on a prescription pad that contains only the hospital’s name and address, he or she must print his or her name legibly on the prescription pad, and include the NPI.

Posted in Medicare Part D and tagged , , , , , | Leave a Comment
25 Jan 2012

Pharmacist groups says CMS, “restricted network” Medicare Part D plans, deceived seniors

The local community pharamcy is often a "non-preferred" phamarcy in Medicare Part D plans.

 

 

As if Medicare Part D wasn’t confusing enough, beneficiaries now have to make sure they watch out for the terms “preferred network” or “restricted network” when choosing a prescription drug plan (PDP).

According to the National Community Pharmacists Association (NCPA), restricted network pharmacy plans are centered on national pharmacy chains (such as CVS or Walgreens) called “preferred network pharmacies.”  These preferred pharmacies offer covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy. (A non-preferred network pharmacy is often the small community pharmacy in your town.)

There are several national restricted network Part D plans, including Humana Walmart-Preferred Rx Plan, Aetna CVS/pharmacy PDP, First Health Value Plus PDP, Rite Aid EnvisionRx Plus, AARP Medicare Rx Preferred, and CVS Caremark Plus.

Last week, the NCPA asked the Centers for Medicare and Medicaid Services (CMS) to create a special enrollment period that would allow members of these plans to enroll in a new Medicare Part D prescription drug plan. The group says this action is needed for patients who believe that “material misrepresentations” led them to sign up for a “preferred network” plan with inadequate pharmacy access.

According to the NCPA, many people have claimed that they relied on CMS’ Medicare Plan Finder, as well as online advertising and/or enrollment agents, to help them find the best plan. They chose a plan based on the low, advertised co-pays, only to find out later the advertised co-pays were only for “preferred network pharmacies.” Now these members may have to travel 20 miles or more to a large chain pharmacy to get that advertised price.

Back in November, NCPA sent a letter to CMS urging the agency to modify the Medicare Plan Finder tool so it is perfectly clear that the lower co-pays are only available at a preferred pharmacy. They also asked CMS to require restricted network plans to clearly state in all communications that members must use a preferred pharmacy to get the lower advertised drug costs.

In a January 19, 2012, press release, NCPA Chief Executive Officer Doug Hoey, RPh, stated, “Every day about 10,000 Americans turn 65 and are eligible to enroll in a Medicare drug plan. Medicare should allow seniors who feel that they’ve been duped the same choice as those just entering the program. In addition, CMS should implement preventative steps to avoid a repeat of this situation next year.”

NCPA is asking community pharmacists to assist their patients in filling out a CMS complaint form, calling 1-800-MEDICARE, or filing a complaint via NCPA’s website if patients feel they were mislead and are experiencing pharmacy access issues.

Posted in Medicare Part D, Restricted Network Plans and tagged , , , , | Leave a Comment
20 Jan 2012
2 Comments

CMS provides Medicare information in American Sign Language

I am very pleased to report that the Centers for Medicare & Medicaid Services (CMS) is making attempts to better reach the Deaf community. Although CMS has always offered information and publications in Braille, large print, and several languages, last month they released a 27-minute introductory video on YouTube in American Sign Language (ASL) for people who are Deaf or hard of hearing. The video gives an overview of Medicare, (including covered preventive services), and discusses the differences between Medicare and Medicaid. Some of the topics include:

• What is Medicare
• Who can get Medicare
• How to enroll if you are eligible
• What are the parts of Medicare
• What will it cost
• What programs are available to help with the costs

Credit goes to Make Medicare Work

Before I give CMS too much credit for this, let me point out that the video was actually produced by a group of Chicago professionals who are Deaf or work with people who are Deaf. The group was spearheaded by Terri Gendel of the Make Medicare Work Coalition’s Deaf Advisory Group and a representative from the office of Rep. Jan Schakowsky’s (D-IL). In addition to this resource, the Deaf Advisory Group has also produced several American Sign Language video fact sheets about Medicare and Medicaid. The fact sheets are also available on DeafMD, a website offering health information from the Centers for Disease Control and the National Institutes of Health in American Sign Language.

Posted in American Sign Language, Medicaid, Medicare, Medicare Part D and tagged , , , ,
16 Jan 2012
3 Comments

When is it NOT medically necessary to prevent illness? And other Medicare coverage questions for CMS

If you read my post last Wednesday, you now know that the shingles vaccine is covered under the Medicare Part D program. What I neglected to tell you—and what I only recently found out after spending a few hours trying to decipher the doublespeak in the voluminous “Medicare & You” handbook—is that there is a very complicated caveat: Your doctor may need to show that the vaccine is “medically necessary” before your prescription drug plan will cover it.

Yep, there it is, buried on page 93, the only single reference to the shingles vaccine in the entire 148-page “handbook”:

 Except for vaccines covered under Part B, Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness. 

The entire sentence is confusing enough, but what exactly does “medically necessary” mean? I wasn’t sure, so I turned to the “Definitions” in Section 8 and read as follows:
Medically Necessary—Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.

OK, but the shingles vaccine prevents a very painful medical condition from occurring in the first place, so it precludes the need for a diagnosis or treatment! Does this mean that a preventive vaccine would never fall under the “medically necessary” category, and therefore, never be covered by Part D?

Now I was getting annoyed, so I decided to call Medicare directly and get an answer. 

After weeding through the automated phone system to get an actual person, a very pleasant-sounding gentleman (Jeff Dean) came to the phone. I told him that I was calling on behalf of everyone who has Medicare and is confused about the shingles vaccine. Here is how Jeff explained it to me:

If you are enrolled in a Part D plan you should find out if the plan covers the vaccine. Some plans may require a prior authorization, which means your doctor must contact the drug plan before you can get the vaccine. Your doctor may need to show that the drug is medically necessary for the plan to cover it—in other words, the doctor must determine that you need it because you are at risk or maybe because you had a shingles outbreak before.

A better example, Jeff explained, is the tetanus vaccine: If you just want to get the tetanus vaccine for the sake of prevention, Medicare will not cover it. However, if you step on a nail while gardening and your doctor orders a tetanus vaccine, it will be covered because it is now considered treatment for a condition (an injured foot).

My next step was to find out just who could be “at risk” for shingles. According to numerous clinical sources, including the Mayo Clinic, anyone who has ever had chickenpox is at risk for developing shingles.  Most adults in the United States had chickenpox when they were children, so just about every adult is at risk for shingles! (The vaccine for chicken pox didn’t come to the U.S. until 1995.) The risk also increases with age and is higher in people with compromised immune systems due to diseases such as HIV/AIDS; cancer treatment; or certain medications used to prevent rejection of transplanted organs.

Some important questions for CMS

So now that I have gotten to the bottom of this issue, I have some questions for the Centers for Medicare & Medicaid Services:

1. When is it NOT medically necessary to prevent illness? (Is illness not a medical condition that should be prevented when possible?)
2. Wouldn’t it be better for everyone in the long run—especially seniors—if Medicare and prescription drug plans paid $100 to help prevent this painful condition rather than $500 or more  later on to treat it?
3. Under the Patient Protection and Affordable Care Act, millions of Medicare beneficiaries now have access to many free preventive services, including an annual flu shot, pneumonia vaccine, and hepatitis B vaccine. Since, theoretically, all adults are at risk of getting shingles, shouldn’t this vaccine also be added to the list?

I have many more questions for CMS — such as, When does a book become so big that it can no longer be called a “handbook”? — but I’ll wait until another time to rant more.

Posted in Medicare, Shingles, Vaccines and vaccinations and tagged , , , ,
23 Dec 2011

Medicare’s moving parts, Part 1: Three strikes you’re out

I often tell people that Medicare is a cluster a moving parts: the parts being A, B, C, D, and so on; the “movement” generated by annual regulatory changes courtesy of the Centers for Medicare & Medicaid Services (CMS). Although these regulations provide job security for many people, they also greatly add to the confusion for Medicare providers, pharmacists, plan sponsors, and of course, beneficiaries.
 
For example, in October, CMS issued Federal Register Volume 76, Number 196, which addresses proposed changes to the Medicare Advantage and Medicare Prescription Drug Benefit programs for 2013. This 161-page, 77,017-word document, with all its sections and sub-sections, is absolutely mind-boggling. Feel free to take a peak here, but don’t say I didn’t warn you!

In my next few blogs, I’m going to try to break it all down and explain some of the points that may be of interest to you and other Medicare beneficiaries.

I want to start, however, by confessing that I’m getting a lot of help from the Medicare Rights Center, a national, nonprofit consumer service organization that works to ensure access to affordable, high-quality health care for Medicare beneficiaries. Click here to check out their excellent e-mail newsletters.

Today I’m going to briefly discuss sections (§) 422.504, 422.510, 423.505, and 423.509, which are grouped together and titled, “Plan Performance Ratings as a Measure of Administrative and Management Arrangements and as a Basis for Termination or Non-Renewal of a Medicare Contract.”  Under this guidance, Medicare Advantage (Part C) and Medicare prescription drug (Part D) plans that receive a summary star rating of less than three stars for three years in a row would be subject to termination.

The proposed ruling states, “A summary rating of less than 3 stars can be achieved only when a sponsor demonstrates poor performance across a range of measures. Therefore, we believe that sponsors that consistently achieve poor plan ratings have demonstrated a substantial failure to comply with the terms of their Medicare contracts.” CMS further states that it believes three years is enough time for a sponsor to develop and put in place corrective action.

In response to this proposed regulation, the Medicare Rights Center states that while it agrees plans with low star ratings should be terminated, three years is too long to allow poor performers to stay in business serving Medicare beneficiaries. “Keeping a low quality plan in the market for three years seems inappropriate and dangerous for beneficiaries,” the center notes in its comments to CMS.

The center also believes that if plans have a one- or two-star rating in any one year, CMS should strengthen incentives for plans to improve quality immediately and better protect beneficiaries. And it recommends CMS consider the use of sanctions or other enforcement mechanisms if a plan’s rating consistently fluctuates between one to three stars; then once a plan with one or two stars improves to three stars, a probationary period should kick in for that plan to ensure it continues to meet adequate performance goals.

I agree that three consecutive years of poor performance is not acceptable. As the writer for a national prescription drug plan that received 5 stars in 2010 and 4 in 2011 (the highest ratings of any national plans in the country), I know first-hand how difficult it is to achieve and maintain a high star rating. But it makes me feel good to know that everyone I work with is taking those extra steps to ensure our members get the service they need to stay healthy and safe. There’s no reason for any plan to continue serving beneficiaries if it can’t achieve a 3-star rating or better in any one year.

Posted in Medicare, Online pharmacies and tagged , , , | Leave a Comment

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