The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “CMS”

Medicare Drops the Ball on New Mail-Order Pharmacy Rule for Part D Members

Medicare drops the ball on seniors

I recently posted two articles about a new Medicare Part D rule that affected beneficiaries who get their medications delivered on a regular basis from a mail-order pharmacy. The rule, which went into effect on January 1, required all pharmacies with home delivery services to get direct consent from Part D plan members before shipping each and every medication.

Today I have some good news to share: The enlightened folks at Medicare have decided that — surprise, surprise — this new rule did not work as intended. Last week, much to our relief, the Centers for Medicare & Medicaid Services (CMS) rescinded the rule.

Full details are still pending, but as of now, you do not need to give your pharmacy permission to ship the medications you regularly receive by mail. It’s probably not quite as simple as this, so if I hear more, I’ll let you know.

If you’re still not familiar with the rule I’m referring to, I’m not surprised. Medicare did a very poor job communicating the details of the rule with Part D plans and beneficiaries.

In a nutshell, the rule required pharmacies to get consent from the plan member (by phone or online) every time the member’s doctor submitted a new prescription or a refill on an existing prescription was ready to be shipped. If the pharmacy didn’t get the member’s consent, it could not ship the medication. No consent, no medication. Period.

As soon as I heard about this rule back in November, I knew it was a recipe for disaster. This rule, I thought, had the potential to create a serious safety issue for seniors and other Medicare beneficiaries. I was right.

Without guidance and communications from Medicare, Part D plans and their members were left in the dark. I tried to provide clear information about the rule for our plan members, but even I found it too complicated to fully understand and explain.

By the first week of March – just two months after the rule went into effect – hundreds of thousands of prescriptions were being held up in mail-order pharmacies throughout the country. Medicare beneficiaries didn’t receive the medications they needed because they didn’t know about the rule or understand how to provide consent. I’m sure many people were very worried and confused when their medications didn’t arrive in the mail on time as expected.

So as I let out a huge sigh of relief, I have something to say to CMS: You really screwed up on this one. By not providing clear communications to Part D plans and members about this complex rule, you created a major safety issue for seniors. You didn’t think it through and consider all the logistics and implications. You dropped the ball and left it up to Part D plans and pharmacies to put it back in play, even though you didn’t provide the rules of the game.


Caution: Stay away from Medicare Part D plans that have received sanctions from CMS

MH900349511This past week, I had to create a letter regarding a Medicare Part D plan that has been sanctioned by the Centers for Medicare & Medicaid Services (CMS) for conduct that “poses a serious threat to the health and safety of Medicare beneficiaries.”

Government sanctions, or penalties, are just one more reason it is critical for you to review your Part D options every year. If you are in a plan that has received sanctions from CMS, you definitely want to look for a plan that has a high star rating (3 ½ stars or better) to make sure you are going to receive the services you pay for and deserve.

SmartD Rx, a new Part D plan from the Smart Insurance Company, is one plan that is not currently accepting enrollments due to CMS sanction action (I guess the company is not so smart). Here is just part of the letter from CMS to Smart Insurance Company regarding its SmartD Rx plan:

The Centers for Medicare & Medicaid Services (CMS) hereby informs Smart Insurance Company (Smart) of its determination to immediately impose intermediate sanctions…

These intermediate sanctions will consist of the suspension of the enrollment of Medicare beneficiaries…and the suspension of all marketing activities to Medicare beneficiaries. CMS is imposing these intermediate sanctions immediately, effective April 23, 2013…because it has determined that Smart’s conduct poses a serious threat to the health and safety of Medicare beneficiaries.

In its short tenure as a Part D sponsor, Smart has experienced widespread failures in numerous important operational areas including:

• Smart inappropriately rejected drug claims at the point of sale (i.e., pharmacy counter);

• Smart failed to properly process coverage determinations (i.e., requests for drug coverage or payment and reimbursement);

• Smart denied enrollees the chance to appeal rejected claims and failed to ensure that denied coverage determinations were reviewed by an independent third party; and

• Smart failed to process enrollment and disenrollment requests, or failed to properly process enrollment transactions.

As a result of Smart’s noncompliance, its enrollees have experienced delays or denials in receiving prescription drug coverage and increased out-of-pocket costs.

CVS Caremark’s SilverScript is another Part D plan that received sanctions from CMS in 2013. In its letter to the SilverScript Insurance Company—a subsidiary of CVS Caremark – CMS wrote:

Since January 1, 2013, SSIC has experienced widespread data system failures that have directly led to extensive violations of the Part D program’s requirements regarding enrollment processing, call center operation, and claims processing. These failures have created disruptions in tens of thousands of Medicare beneficiaries’ access to prescription medications.

 From January 1 through January 14, 2013, CMS received 2,340 complaints about SSIC’s Part D operations. CMS has received complaints about SSIC at a rate four times greater than the rate of complaints received about all other Part D sponsors combined during the same period.

Other Medicare plan sponsors that have been sanctioned by CMS in the past include HealthNet,  Arcadian, and Universal American (all 2010), and Universal Health Care Insurance Company (2013). You can go to the Part C and Part D Enforcement Actions page on the CMS website for a complete list of plans that have received sanctions and other enforcement actions or had sanctions lifted.

How to get out of a bad Medicare plan

If you are enrolled in a plan that has been sanctioned, and you have personally been affected by your plan’s poor performance, you may be able to get out and switch plans outside of the Open Enrollment period. Your chance to switch is determined by CMS on a case-by-case basis, so you’ll need to call Medicare at 1 800 MEDICARE (1 800 633-4227), 24 hours a day, 7 days a week. TTY: 1 877 486-2048. Or go to this page at for more information.

The Blind Leading the Blind: Anatomy of a Medicare Part D Monthly Premium

At least once a week one of my coworkers on our Medicare Part D team will come to me with what they think is a simple job. ‘I just need you to write a short apology letter. It should be simple,” Karen will tell me. “I have a simple project for you. All you have to do is edit this web page for Medicare Open Enrollment,” Tina will say. “We just need to ‘Medicarize’ this brochure, so it will be simple,” Chris will state.

Inevitably, I always respond, “Nothing is simple with Medicare Part D.” And then as what appeared to be an easy project becomes more complex with each new logistical problem that arises, I say, “I told you so.”

One of the most complicated “parts” of Part D – and thankfully, one that I have absolutely nothing to deal with – is what we call the annual Medicare bidding process. As our director of actuarial services notes, the process of bidding on Medicare prescription drug plans is a lot like putting together a giant puzzle. When the puzzle is completed, you end up with a monthly Part D premium of $32.07 or $41.29 or some other odd amount that seems completely random.

Unlike the commercial insurance market where providers set the premiums for a plan, Medicare Part D premiums are determined as part of a blind bidding process that begins in June of each year. Every Part D provider submits bids to the Centers for Medicare & Medicaid Services (CMS) without knowing what the competitors will offer. Then CMS sets premiums based on how the bids average out. Premiums may vary from what providers submitted depending on what their competitors bid and how they differ from expectations.

A few large competitors dominate the marketplace, so the ability to predict premiums, profitability and potential membership growth requires an educated guess as to how other Part D providers will bid. The guesswork can be quite complex and requires a detailed understanding of trends and potential growth strategies in the marketplace.

For example, is a large Part D provider going to try to maximize profits by bidding a higher number or are they looking to increase membership and so plan on submitting a lower bid to CMS? Data and historical trends are helpful, but it’s really more of an art than a science when it comes to making a good bid that has competitive premiums and features that Medicare beneficiaries want in a Part D plan.

During the next two months, CMS will thoroughly review each bid. In August, CMS will release the bid results, giving marketing departments and employees like me just barely enough time to create all the plan materials and marketing communications for Medicare Open Enrollment in mid-October.

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.


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.

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.

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.

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.

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.

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.

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