The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “Medicare beneficiaries”

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 Last week, much to our relief, the Centers for Medicare & Medicaid Services (CMS) rescinded the rule.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.


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.

Yes, you can switch your pharmacy at any time with Medicare Part D

Walgreens survey about Medicare Part D

This infographic from Walgreens explains some of the findings from a recent survey regarding beliefs about Medicare Part D.

Today I had an “ah ha!” moment at work.

For years I have been telling the over 2 million Medicare beneficiaries in my company’s Part D prescription drug plans that they can often save money by using a different pharmacy. Using a mail-order pharmacy almost always yields savings, as does switching to a preferred retail pharmacy that offers lower co-pays or moving to a pharmacy that simply charges less money overall for prescription medications.

And for years I have been wondering why so few Part D plan members are taking my advice and using a more cost-effective pharmacy. Why aren’t seniors taking advantage of these savings opportunities?, I have often asked my coworkers and friends.

This morning I came across the results of an April 2013 Walgreens survey that answered my question — or at least, provided one explanation.   According to the survey, almost 30% of the 1,000 beneficiaries surveyed did not know that they can switch pharmacies at any time during the year. These 300 Medicare enrollees falsely believed that they could only switch to a new pharmacy during Medicare’s annual Open Enrollment Period.  In other words, they thought that if they were using XYZ Pharmacy when they first enrolled in a plan, they’d have to stick with XYZ until Open Enrollment (October 15 to December 7 of each year).

Although many Medicare beneficiaries shun mail-order pharmacies, even though using mail order is one of the best ways to save, retail pharmacies in a preferred pharmacy network are a great alternative for some people. Using a preferred pharmacy — if the Part D plan offers a preferred pharmacy network and there is a preferred pharmacy close to home — can potentially save beneficiaries hundreds of dollars each year on prescription drug co-pays.

However, it looks as though few people are taking advantage of preferred pharmacies. In fact, only 21 percent of respondents switched to a pharmacy within their plan’s preferred network as a way to save. One-fourth (24 percent) said they were unaware of whether their plan offers a preferred pharmacy option.

The survey  “underscores the need to educate Part D beneficiaries about how they can save on prescription and other health care costs,” said Dan Luce, director of pharmacy affairs, Walgreens. Many more Medicare Part D plans are starting to offer preferred pharmacy networks, so I guess I have my work cut out for me.

On Medicare and live in the South? Make sure you’re not taking a high-risk drug.

Seniors in the Southeast are more likely to be prescribed at least one one high-risk medication.

Senior Medicare beneficiaries in the Southeast are more likely to be taking at least one high-risk drug.
Source: NPR (Dany Qato and Amal Trivedi/Alpert Medical School, Brown University)

As I mentioned in my last post, recent findings from Express Scripts show that Medicare providers in New York, New Jersey, and several southern states are less likely to prescribe lower-cost generic drugs then their counterparts in Midwestern states.

Now a new study from the Alpert Medical School at Brown University finds that more than 20 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan are taking at least one high-risk medication. And beneficiaries who live in parts of the South are even more apt to be prescribed high-risk medications. In fact, in many parts of the South – especially the Southeast – more than one-third of seniors are taking drugs that, according to Medicare guidelines, are considered high risk for people age 65 and older.

For example, more than 38 percent of Medicare Advantage enrollees in Albany, Georgia, were prescribed at least one risky drug, compared to 10 percent in Mason City, Iowa, the area with the lowest rate. Beneficiaries prescribed risky drugs were also more likely to be poor, white, and female.

So why are Southerners more likely to be prescribed risky meds? According to the authors of the study, it could be that patients are asking their doctors for them. Or it could be that doctors in these regions are more apt to stick with old prescribing habits. Neither one of these reasons is a valid excuse.

Why are some drugs classifed as risky?

Certain medications are associated with a high risk of side effects and drug toxicity in the senior population, and pose a concern for patient safety. Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage plans to report prescribing rates of high-risk medications.

Many drugs are classified as risky because they stay in the body longer, increasing the risk of falls and fractures. Others are classified as drugs to be avoided in people 65 years or older because they are simply not effective enough to be used on a regular basis.

Risky drugs for seniors include amphetamines, barbiturates, muscle relaxants, and narcotics. Old-style sedating antihistamines and medications for depression and anxiety (like long-acting diazepam or Valium®) are also risky, as they can cause sleep apnea or cardiac arrest.

What drugs should be avoided?

The Centers for Medicare & Medicaid Services (CMS) has published a list of high-risk medications to be avoided in patients 65 years and older. Doctors should have this information, but patients and caregivers also need to be aware of this list. The authors of the study — a pharmacist and a medical doctor — suggest that people talk with their doctors about risky medications and make an appointment with their pharmacist to review all their medications to find out if any should be stopped or replaced with a less risky drug.

You should also check the star ratings of your Medicare plan (Part D or MA-PD) if you have prescription drug coverage. CMS awards lower star ratings to Medicare plans if a certain percentage of the plan’s members age 65 and older receive a medication that puts the patient at high risk for an adverse drug-related event, such as a fall or cardiac event. When reviewing Medicare plans, you should ask how the plan scored under “Drug pricing and patient safety.” If you live in the South and your plan has a low star rating in this category, you should definitely be on the alert for prescriptions for high-risk medications.

Finding a Doctor Who Accepts Medicare | PBS NewsHour

Finding a Doctor Who Accepts Medicare | PBS NewsHour.

Don’t Accept a Provider That Doesn’t Accept Medicare: No Exceptions

Medicare home health representativeI received an e-mail from my cousin Michelle about one of her clients, who had a very uncomfortable experience with a Medicare provider. According to Michelle, her 85-year-old client, Bill, had just undergone some surgery and was now recovering at home. He received an unwelcome – and surprise – visit from a woman who said she was from a home healthcare agency.

The woman told the man that she was sent by the hospital, and that her agency worked with Medicare. She also told him that he had to sign some papers authorizing the agency to provide his home health services.

“My client did not know anything about this woman or her agency, and the woman was very rude to him when he questioned her,” Michelle wrote to me. “He refused to the sign the documents. Was that the right thing to do?”

I had a lot of concerns about this scenario, so I immediately replied to Michelle. Here is a summary of my email to her:

• It was definitely Bill’s right to question the woman, especially since he didn’t know anything about her or her company.
• He was also right to refuse to sign any paperwork.
• Bill should contact the hospital or his doctor to confirm that the hospital had in fact contracted with the woman’s agency to provide home health care. If so, he should let the hospital or doctor know that he is not pleased that this decision was made without his consent or knowledge.
• Bill should tell the hospital or physician that the woman who came to his home was very rude, and that he would not be comfortable receiving services from this agency.
• Finally, should Bill decide to use this agency for home health services, he must first confirm that the agency is a Medicare participating provider – or in other words, accepts Medicare assignment. Just because the woman said her agency works with Medicare doesn’t automatically mean the agency is a Medicare participating provider.

What is a Medicare Participating Provider – and Why is it Important?
Participating providers have signed an agreement to accept assignment for all Medicare-covered services. In simpler terms, it means they agree to accept the Medicare-approved amount as payment in full, and will not charge patients any more than the approved amount. They also agree to charge you only the Medicare deductible (if applicable) and coinsurance amount.

Non-participating providers, on the other hand, can charge you up to 15 percent more than the Medicare-approved amount. They can also request that you pay the full cost up front at the time of service, which means you will have to wait for Medicare to reimburse you.

Most doctors, providers, and suppliers accept assignment, but you should always check to make sure. Medicare offers a search tool on its website that I suggest you use each time you see a new doctor, or, like in Bill’s case, a strange woman comes to your door and wants you to sign some papers.

Medicare rejects claim because man’s name is too long

Not enough spaces on Medicare enrollment form

Looks like they need more spaces on the Medicare enrollment forms.

Here’s another Medicare story from the files called “You Can’t Make This Stuff Up.”

Turns out a retired Spokane man who has been using his Medicare benefit since 2009 no longer exists in the Medicare computer database. Apparently, he simply has too many letters in his last name.

As the story goes, Robert Lautzenheiser recently received a bill from a doctor visit, but it didn’t show a payment by Medicare. The billing office told him his Medicare claim was rejected because his name was incorrect.

Apparently, the “r” at the end of his last name does not appear on his Medicare card, even though his full name is displayed on his driver’s license and Social Security card. So Medicare was not about the pay a claim for a Robert Lautzenheiser who was using Robert Lautzenheise’s Medicare benefit.

According to Robert, the card does not have his entire name because when he originally filed for Medicare in 2009 there weren’t enough spaces on the form to fit it. “Well when someone like Jones makes up the database,” Robert told KHQ News, “they don’t think about how long last names can be.”  

In the past, Robert said he used paper billing, so a human could double-check and correct the error. But with a new electronic filing system, the computer says he doesn’t exist.  Robert says he thinks it should be as easy as adding the letter into a database, but instead he has to go through lots of bureaucratic red tape to convince the government that he really exists and is entitled to his Medicare benefits. 

Hmmmm, I wonder why this doesn’t surprise me. After all, Medicare and red tape go hand in hand!

By the way, I checked the enrollment form for my company’s Medicare Part D plan, and it has 35 spaces for the last name (the online version of the form has unlimited spaces). We’re working on re-designing this enrollment form, so I will make sure that our graphic designer doesn’t take away any spaces!

Medicare Part D premiums not expected to rise in 2013

Today the Obama administration announced that the average premium for basic Medicare Part D drug coverage will stay the same next year, at around $30 a month. This makes three years in a row that the monthly Part D premium has stayed in the $30 range for Medicare beneficiaries.

Because we’re dealing with Medicare, there is, of course, a caveat. The $30 amount is just an average, so some beneficiaries may pay a higher premium amount in 2013, while others may pay less. That’s why it’s so crucial to check your plan during open enrollment season this fall (October 15 to December 7) and shop around if your costs go up too much or you’re just not satisfied with your plan.

Why it’s important to choose a plan with the lowest total cost

Although premiums are important, if you’re shopping around for a new Medicare Part D plan, you should look for a plan that offers the lowest total cost based on the medications you take. I really can’t stress this point enough.

All too often, Medicare beneficiaries will choose a plan with the lowest monthly premium, only to find out weeks or months later that they’re going pay more in the long run. It may be that the co-payments for their medications are higher in this “low-cost” plan, or they have a higher annual deductible. As I have mentioned before, remember to consider the monthly premium plus the annual costs for all your medications when making your decision.


Mission ola lāhui: Increasing awareness of preventive services covered by Medicare in Hawaii

Medicare beneficiaries in HawaiiThis morning I read in Kaiser Health News that only 1 percent of Medicare beneficiaries living in Hawaii have taken advantage of the free annual wellness visit they are entitled to, courtesy of healthcare reform. I immediately sent a tweet via Twitter to my friend Claire Santos, RN, who is a nurse and health communicator and educator in Hawaii. Claire, I tweeted, you now have a mission to increase awareness of preventive services covered by Medicare in your home state.

According to the Centers for Medicare & Medicaid Services, only 890 beneficiaries in the Aloha State have had a free wellness exam this year, which is the lowest percent of any state. Even worse, the state with the highest percentage of seniors who have taken advantage of the wellness visit is Rhode Island — coming in at just 8 percent. 

Nationally, only about 3.6 percent of beneficiaries, or 1.1 million seniors, have had a wellness visit since January.  Jim Firman, CEO of the National Council on Aging (NCOA), a nonprofit advocacy group, theorizes that many seniors simply do not know what additional Medicare benefits are provided in the Affordable Care Act. Speaking at a White House event highlighting benefits to seniors in the health law, Firman said of the annual wellness visit, “This is a really good benefit, but you have to use it to maximize the opportunity.”

What exactly is the annual Medicare wellness visit?

It’s important to understand that the wellness visit is not a physical exam. It’s actually just a great opportunity to talk to your doctor and develop or update a personalized prevention plan based on your current health and risk factors. Anyone who has had Medicare Part B for longer than 12 months is eligible for this annual visit, which includes: 
• A review of medical and family history
• A list of current providers and prescriptions
• Height, weight, blood pressure, and other routine measurements
• A screening schedule for appropriate preventive services
• A list of risk factors and treatment options for you

Other preventive services covered by Medicare

Thanks to the Affordable Care Act, numerous preventive services are now provided free under Medicare. These services include various exams, shots, lab tests, and screenings, plus counseling and education to help you take care of your own health. This year, only 43 percent of Medicare beneficiaries, or about 14 million people, have taken advantage of the free care this year.  CMS put out a great guide to Medicare’s preventive services, which I highly recommend you check out if you are among those eligible who have not yet taken advantage of these services – especially if you are among the 99 percent of beneficiaries in Hawaii who have not yet had your wellness visit.

By the way, if you’re wondering what “ola lāhui” means: According to online sources, it is defined as, “So that the people will live and thrive.” The term is often used with health care services or professionals — like my friend Claire — to show intent to improve the health and being of the Hawaiian people.

Why Romney’s pass on Medicare matters

Why Romney’s pass on Medicare matters.

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