The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “Medicare”

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 Last week, much to our relief, the Centers for Medicare & Medicaid Services (CMS) rescinded the rule.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


How the DMEPOS Medicare Competitive Bidding Program could affect you

MB900366334If you are a Medicare beneficiary and have Original Medicare you may have received a notice from Medicare in May about the Durable Medical Equipment Competitive Bidding Program. This program was put in place to help lower the costs of durable medical equipment and supplies for people with Original Medicare. The program is expected to help Medicare beneficiaries save $17 billion between 2013 and 2022.

 In January 2011, Medicare began phasing in the Competitive Bidding Program in some parts of the country. The program requires providers and suppliers of certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to submit bids for their products. Qualified suppliers with winning bids who meet strict quality and financial standards are then chosen as Medicare-approved contract suppliers.

Under this new program, if you have Original Medicare and live in a competitive bid area, you almost always have to use a Medicare contract supplier if you want Medicare to pay for certain DMEPOS products and services. According to Medicare guidelines, durable medical equipment (DME) is equipment that:

  • Serves a medical purpose;
  • Can be used in your home;
  • Can be used over and over again;
  • Is likely to last for 3 years or more; and
  • Is prescribed by your doctor or other health care professional.

Some examples of DME include walkers, wheelchairs, power scooters, diabetic testing supplies, and oxygen tanks.

The DME Competitive Bidding Program only affects those with Original Medicare, the traditional Medicare program directly administered by the federal government (Part A and Part B). It does not affect those who have a Medicare Advantage plan, also known as a Medicare private health plan. If you have a Medicare Advantage plan, you should contact your plan to see which suppliers are in the plan’s network of providers and will provide DME to you at the lowest cost.

The main purpose of the Competitive Bidding Program is to replace the prices Medicare currently pays for DMEPOS items with lower, more accurate and more current market prices. By using prices set through competition and ensuring suppliers are all licensed and accredited, the program will:

  • Reduce your out-of-pocket expenses
  •  Help Medicare and taxpayers save money
  • Ensure you have access to quality supplies and services from reliable suppliers
  • Help reduce Medicare fraud and abuse

Important News about Diabetic Testing Supplies

As of July 1, 2013, the Competitive Bidding Program was expanded to 91 regions of the United States. It was also expanded on a national level for mail-order providers of diabetes testing supplies. If you order your diabetes testing suppliers through the mail, you must now use a Medicare contract supplier if you want Medicare to cover your costs. Medicare will still provide coverage if you get your supplies from a drugstore or other retail facility, but you will pay less by using mail order.

For more information about how this program may affect you, check out the website. This site has a good article about the Medicare Competitive Bid Program as well as an online tool to search for a DMEPOS supplier.

If you use diabetes testing supplies, check out the article Diabetic Supplies and the Competitive Bidding Program or get a list of Competitive Bid Winners. The site also has articles about how the program will affect you if you use other equipment such as a power scooter or oxygen supplies.

To find out whether you are affected by the Competitive Bidding Program, you can also contact 800-MEDICARE or go online and visit

Medicare No Longer Pays for Vitamin B-12 Injections — and it’s All Obama’s Fault

Medicare True or False
Is the headline of this post true or false?

If you are a person who believes everything you read on the Internet, then you may be inclined to say it’s true. If, on the other hand, you question everything that sounds too good to be true or simply too unbelievable, then you probably think it’s false—but you’re going to do more research to double-check.

A recent State Farm commercial features a man and a woman discussing mobile apps. During the conversation, the man asks the woman why she believes something he said, and she tells him it’s because she read it on the Internet. “They can’t put anything on the Internet that isn’t true,” she tells him. Right then, an unattractive man walks into view. The woman tells her friend that the boorish man said he was a French male model on the Internet.

The point is, there are a lot of lies out there on the World Wide Web. And many of them have to do with horrible changes to Medicare coverage under the Patient Protection and Affordable Care Act (ACA). Many of the lies are ludicrous and primarily designed to instill fear in people.

The other day, my mom sent me an e-mail that she had received from a former coworker. She told me she was concerned about some of the things the letter said about Medicare coverage under the ACA, aka, Obamacare. Here’s just one excerpt from the e-mail:

Today I went to the doctor for my monthly B-12 shot that I have been getting for a number of years. The nurse came and got me, got out the needle filled and ready to go and then looked at the computer and got very quiet and asked if I was prepared to pay for it. She said that Medicare had turned it down and went to talk to my doctor about it. Fifteen minutes later she came back and said she was sorry, but they had tried everything they could but Medicare is beginning to turn many things away for seniors because of the projected Obamacare coming in.

I did some quick research on and and found out that this letter was one of many that began circulating when Congress was considering a healthcare bill called America’s Affordable Health Choices of 2009 (H.R. 3200). This bill was never passed by Congress. However, the letters continue to circulate, even though most of the points made in these letters are completely irrelevant, outdated, and have nothing to do with Obama’s Affordable Care Act (H.R. 3590).

Yes, Medicare does pay for B-12 injections – if deemed reasonable and necessary
Under Section 1862 (a) (1) (A) of the Social Security Act, Medicare covers services that are deemed reasonable and necessary “for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” For example, vitamin B-12 injections are covered, but only for diagnoses such as pernicious anemia, gastrectomy, and dementias secondary to vitamin B-12 deficiency. In addition, the frequency and duration of the administration of the medication must be within accepted standards of medical practice, or there must be a valid explanation regarding the extenuating circumstances to justify the need for the additional injections.

You should also make sure your doctor’s office uses the correct codes when billing Medicare for B-12 injections. According to what I read on the American Academy of Professional Coders website, some Medicare Advantage Plans will not pay for the injection if the doctor also bills Medicare for an Evaluation and Management service. Other plans require a diagnosis code in addition to the codes for the administration and drug code. So if you get your coverage from a Medicare Advantage Plan or Medigap supplemental plan, you should ask what documentation the plan requires for coverage before getting your first injection.

Live in New York or New Jersey? Better speak up and ask for that generic drug.

Location generic drugsBritish real estate developer Lord Harold Samuel once said, “There are three things you need in property. These are location, location, and location.” Apparently the same is true when it comes to prescribing generic drugs for Medicare beneficiaries, too.

According to the Express Scripts 2012 Drug Trend Report, where you hang your hat will frequently determine how often your doctor will prescribe a generic drug for you: Medicare providers in New Jersey, New York, and southern states such as Texas and Louisiana prescribe fewer cost-saving generics than their counterparts in Midwestern states such as Ohio and Wisconsin.

“A prescriber’s geographic location is a strong predictor of the proportion of generic prescriptions they write,” says Sharon Frazee, vice president, Research & Analysis, Express Scripts. “Location encompasses many features that have a complex influence on prescribing and utilization.” Some of the regional features that influence the prescribing and utilization of generic drugs include income levels, the impact of media markets and advertising dollars, and the proximity to urban centers and healthcare services.

Here are some other interesting trends that can help predict which healthcare providers are more apt to prescribe generics:

• Younger, less tenured healthcare providers, including physicians, nurse practitioners and physician assistants, are more likely to prescribe generic medications to Medicare patients than older providers with more years in practice.
• Prescribers who care for a large number of Medicare patients are more likely to prescribe generics than those with fewer Medicare patients.
• Prescribers who practice in rural areas adjacent to large cities are more likely to prescribe generics than prescribers in metropolitan areas and urban centers.

One possible explanation for these findings has to do with habit and experience: Some healthcare providers have been practicing medicine longer than many generic drugs have been on the market. They may prescribe the brand drugs with which they are familiar and that have worked well for their patients out of habit, without giving any thought to the cost. If their patients don’t speak up and ask about generic drugs, they’ll immediately fill out the script for the brand-name drugs they know the best (this is especially true if the physician has pre-printed scripts for certain popular brands).

As I have mentioned in previous posts, brand-name drugs, especially “blockbuster drugs” like Lipitor® and Plavix®, are often a lot more expensive than their generic counterparts. And if pricing trends from 2011 to 2012 are any indication, I wouldn’t expect prices on brand-name drugs to come down anytime soon.

The increasing availability of lower-cost generic drugs offers significant savings opportunities for Medicare beneficiaries – but unless you speak up and specifically ask your healthcare provider to prescribe generics whenever possible, you may never enjoy these added savings. Especially if you live in New York or New Jersey.

Finding a Doctor Who Accepts Medicare | PBS NewsHour

Finding a Doctor Who Accepts Medicare | PBS NewsHour.

Don’t Settle for Lousy Customer Service in Your Medicare Plan.

Don't settle for a bad Medicare plan

Don’t get stuck in a jam if you don’t like your Medicare plan.

I recently came across a slew of complaints about the SilverScript Medicare Part D plan on the Complaints List website. (SilverScript is sponsored by the SilverScript Insurance Company, which is an affiliate of CVS Caremark.) The majority of complaints were about the drug plan’s customer service – or alleged lack thereof.

For example, Rita posted this complaint:

I’ve been treated rudely, after waiting on hold for an hour plus, sent to someone else after another 45 minutes, then that person said to hold and hung up on me. There should be a law about these customer service people treating the disabled elderly with more respect. Their day will come too. I feel as if they don’t care if we live or die and if we die without our meds they would be happy.

Now, I need to point out that last month the Centers for Medicare and Medicaid Services took action against SilverScript for issues related to claims processing (for example, some claims for new members were being rejected at pharmacies). Many of the complaints on the Complaints List website may be tied to this claims processing issue; however, it appears that the SilverScript customer service reps have not been properly trained on how to help people and treat them with respect.

No one should have to deal with horrible customer service. That’s why Medicare has established a 5-star special enrollment period.

Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to plans. As I’ve mentioned before, low star ratings typically mean lower quality and poor customer service.

Last year SilverScript earned only 3 stars from Medicare. This was the lowest star rating among the top 10 Medicare Part D plans in 2012. Based on all the complaints I’ve read, it won’t surprise me if the plan’s ratings drop even lower for 2013.

Here’s the good news for Rita and everyone else who has complaints about his or her Medicare plan: You may not have to settle for a plan with bad customer service all year long. That’s because you can switch to a 5-star Medicare Prescription Drug Plan or Medicare Advantage Plan if you are not happy with your current plan. The Special Enrollment Period for joining a 5-star plan runs from December 8 through November 30 every year.

Although very few plans have earned a 5-star rating from CMS this year, if you’re fortunate enough to find one that serves your area, you can disenroll from your current plan if you’re not satisfied and join a plan that has earned 5 stars.

Use the following resources to get plan 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 should call 1-877-486-2048.
• You can download the Medicare fact sheet, which has additional information about star ratings.

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.

Dear Medicare, We’re not Dead Yet

In Monty Python’s Spamalot, there is a scene with Robin and Lance and a supposed dead man who suddenly rises from a cart singing, “I am not dead yet; No need to go to bed; No need to call the doctor; Cause I’m not yet dead.”

Arnold Ross of New York also sang this song—although not to an audience, but to Medicare. Unfortunately, the people at the Centers for Medicare & Medicaid Services apparently had their ears plugged.

According to this report I came across on Eyewitness News, ever since Arnold’s wife passed away in July, Medicare has declared Arnold dead. “They said I’m deceased. I was dead in their computers,” he tells the reporter. “Look at me, do I look dead?” he said.

Weeks after his wife’s death, Medicare sent Arnold a condolence letter for his own death. Medicare also stopped paying his doctor bills. Arnold says he made many calls to Medicare, but nothing was ever resolved. Eyewitness News made one call and the problem was resolved in a few hours.

Medicare said the initial confusion happened because Arnold and his wife’s Medicare numbers were very similar (in other words, a computer error). They apologized to him for the problem, but couldn’t explain why it took so long to pay attention to his pleas and get it fixed.

A few years back I ran into a similar problem with Medicare — they had accidentally attempted to enroll people into a Medicare Part D plan even though these people had passed away. (Imagine getting a letter thanking your late spouse for joining a Medicare plan.) I had to write a letter to their loved ones expressing condolences for this error.

Unfortunately, because Medicare relies on enormous computer systems to operate, mistakes do happen often. But there was no excuse for the real people at Medicare to ignore Arnold’s calls when their computer system made an error. Talk about Medicare fraud, waste, and ABUSE. If I were in charge, a lot of people would be fired right now for their incompetence.

Online tool helps people locate open pharmacies in storm-affected areas

During a disaster or emergency event, it is critical for people who take life-saving medications or drugs that control chronic conditions to have access to those medicines. I discovered this firsthand when my mom came to stay with me during Hurricane Sandy. She originally planned on staying only one night—she was overly optimistic about the power coming back on at her house—but when she heard the power was going to be off for at least a few more days, Mom began to panic a bit. She only brought a two-day supply of her medication, and was worried about having to skip a few days without it.

Luckily I know a thing or two about Medicare Part D, and was able to explain the situation to the CVS pharmacist in town. Even though my mom had just refilled her medication a few days earlier at her local CVS, the pharmacist was able to override Medicare’s  “Refill too soon” claim rejection because of the emergency situation. Within 10 minutes, Mom had her medication in hand.

We were very fortunate in that my home town did not sustain any damage, so I knew there would be no trouble getting her medication. But what about the less fortunate people in areas like Staten Island, Rockaway Beach, and Long Beach Island, where so many homes are in ruins? How would people know where to go to get the medication they needed?

I started to do some digging on the subject, and came across the Rx Response’s Pharmacy Status Reporting Tool.  The website provides real-time information about open pharmacies in storm-affected areas.  Granted, one needs Internet access via computer or smart phone to use the site, but it’s still a good tool for those employees and volunteers in emergency management and at emergency shelters who are trying to help people find the closest open pharmacy.

According to the site, Rx Response works with the National Council for Prescription Drug Programs (NCPDP) and pharmacy clearinghouses responsible for processing pharmacy payments. Once a request is made by a state emergency or public health official to begin pharmacy status reporting, Rx Response requests a list of all NCPDP pharmacies within an affected disaster area as well as a daily list of all pharmacies that are billing within the affected area. Once the data is processed, Rx Response displays a graphical, searchable map and downloadable Excel file of all known pharmacies, all open pharmacies, and any known affected/closed pharmacies.

The site is a bit clunky and not very user-friendly, but the concept is a good one that is much needed in this age of frequent storm surges. If anyone knows of a better site with this type of information, please let me know. With Sandy Part II expected to hit the northeast today and tomorrow, a lot of people may unfortunately be searching again for an open pharmacy.

What do online pharmacies and mystery meat have in common?

Mystery meat and online pharmacies: you never know what you're gettingReport shows almost all online pharmacies are fake, don’t follow U.S. laws.

As drug prices continue to rise, many Medicare beneficiaries are turning to the Internet to find cheaper drugs at online pharmacies. It may be tempting to use an online pharmacy, especially one of the many “Canadian online pharmacies,” but drugs purchased from these sites often come with some big risks.

Rogue websites are all over the Internet selling drugs that may be counterfeit, contaminated, or otherwise unsafe. In addition, about 16 percent of Internet drug outlets do not have secure sites, which means your personal and financial information could be at risk if you place an online order. In a nutshell, when you buy from an online pharmacy, it’s just like choosing the mystery meat in the cafeteria: You never know what you’re getting.

According to the a 2012 Internet Drug Outlet Identification Program Progress Report from the National Association of the Boards of Pharmacy (NABP), 97 percent of the more than 10,000 websites they reviewed are operating out of compliance with U.S. pharmacy laws.  Many of these so-called pharmacies are unlicensed, operating illegally, or operating from foreign countries where drugs shipped to the U.S. are unregulated. If you buy from one of these online pharmacies, you run a high risk of receiving drugs that may be:
• Contaminated
• Sub-potent
• Super-potent
• Expired
• Counterfeit
• Improperly stored and shipped (and thus, may not be as effective)

O Canada! That website might not be what it seems
Lots of seniors I talk to tell me they get their drugs from a Canadian online pharmacy because of the cheaper prices. The problem is, although it may call itself a “Canadian pharmacy,” it may actually get its drugs from countries in Asia, South America, or Eastern Europe, where quality standards are less stringent and counterfeit drugs more widespread.

Beware of an online pharmacy that shows these signs of being fake
Fake online pharmacies can manipulate their websites to appear legitimate, so if you still insist on getting your drugs this way, make sure you avoid any online pharmacy that:

• Lets you buy drugs without a prescription from your doctor
• Offers cheap prices that seem too good to be true
• Sends spam or unsolicited email offering cheap drugs
• Is located outside of the United States
• Is not licensed in the United States

Look for these signs of a safe online pharmacy:
• Always requires a doctor’s prescription.
• Provides a physical address and telephone number in the United States.
• Offers a pharmacist to answer your questions.
• Has a license with your state board of pharmacy.  Check here find out.

 Verified Internet Pharmacy Practice Sites

To minimize your risk when using an online pharmacy, be sure to look for the VIPPS seal.

An easy way to find accredited online pharmacies
To help you make an informed choice, NABP reviews thousands of websites to determine if they maintain safe pharmacy practices.  NABP recommends using sites accredited through the VIPPS (Verified Internet Pharmacy Practice Sites) program. Look for the VIPPS seal, which is a symbol of a pharmacy’s commitment to its patients’ health and safety. Currently, only 50 sites, or about 3% of the online pharmacies NABP has reviewed, have received accreditation.

You can also check out this list of Internet drug outlets that appear to be out of compliance with state and federal laws or NABP patient safety and pharmacy practice standards.

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