CHA Blog

• 17Aug

  Health Reform Gives Some Immediate Benefits for Californians

  Health Care Reform, Medicare and other health insurance, Prescription drugs, Resources No Comments

  Health care reform changes are vast and include many changes that will affect Americans now and in the future. While we’ve focused several articles on the changes affecting Medicare and Medicare beneficiaries, this article below, focuses on those affecting Californians old and young. Excerpted from the Passages HICAP Recap July-August 2010 newsletter (PDF), this article lists some of these changes and explains some of the immediate benefits impacting Californians.

  Small business tax credits

  503,000 small businesses in California could be helped by a new small business tax credit that makes it easier for businesses to provide coverage to their workers and makes premiums more affordable. Small businesses pay, on average, 18% more than large businesses for the same coverage, and health insurance premiums have gone up three 3 faster than wages in the past 10 years. This tax credit is just the first step towards bringing those costs down and making coverage affordable for small businesses.

  Closing the Medicare Part D donut hole

  Last year, roughly 382,000 Medicare beneficiaries in California hit the donut hole, or gap in Medicare Part D drug coverage, and received no extra help to defray the cost of their prescription drugs. Medicare beneficiaries in California who hit the gap this year will automatically be mailed a one-time $250 rebate check. These checks began being sent to beneficiaries in mid-June and will be mailed monthly throughout the year as new beneficiaries hit the donut hole. The new law continues to provide additional discounts for seniors on Medicare in the years ahead and completely closes the donut hole by 2020. (See our past blog article, Are You Eligible for the Part D Rebate: Q & A for more info.)

  Support for health coverage for early retirees

  An estimated 430,000 people from California retired before they were eligible for Medicare and have health coverage through their former employers. Unfortunately, the number of firms that provide health coverage to their retirees has decreased over time. On June 1, 2010, a $5 billion temporary early retiree reinsurance program started to help stabilize early retiree coverage and help ensure that firms continue to provide health coverage to their early retirees. Companies, unions, and state and local governments are eligible for these benefits.

  New consumer protections in the insurance market beginning on or after September 23, 2010

  • Insurance companies will no longer be able to place lifetime limits on the coverage they provide, ensuring that the 19 million California residents with private insurance coverage never have to worry about their coverage running out and facing catastrophic out-of-pocket costs.

  • Insurance companies will be banned from dropping people from coverage when they get sick, protecting the 2.7 million individuals who purchase insurance in the individual market from dishonest insurance practices.

  • Insurance companies will not be able to exclude children from coverage because of a preexisting condition, giving parents across California peace of mind.

  • Insurance plans’ use of annual limits will be tightly regulated to ensure access to needed care. This will protect the 16.2 million residents of California with health insurance from their employer, along with anyone who signs up with a new insurance plan in California.

  Health insurers offering new plans will have to develop an appeals process to make it easy for enrollees to dispute the denial of a medical claim. Patients’ choice of doctors will be protected by allowing plan members in new plans to pick any participating primary care provider, prohibiting insurers from requiring prior authorization before a woman sees an ob-gyn, and ensuring access to emergency care.

  Extended coverage to young adults

  Beginning on or after September 23, 2010, plans and issuers that offer coverage to children on their parents’ policy must allow children to remain on their parents’ policy until they turn 26, unless the adult child has another offer of job-based coverage in some cases. This provision will bring relief to roughly 196,000 individuals in California who could now have quality affordable coverage through their parents. Some employers and the vast majority of insurers have agreed to cover adult children immediately.

  Affordable insurance for uninsured with preexisting conditions

  $761 million federal dollars are available to California starting July 1 to provide coverage for uninsured residents with pre-existing medical conditions through a new transitional high-risk pool program, funded entirely by the Federal government. The program is a bridge to 2014, when Americans will have access to affordable coverage options in the new health insurance exchanges and insurance companies will be prohibited from denying coverage to Americans with pre-existing conditions. If states choose not to run the program, the Federal government will administer the program for those residents.

  Strengthening community health centers

  Beginning on October 1, 2010, increased funding for Community Health Centers will help nearly double the number of patients seen over the next 5 years. The funding could not only help the 1,049 Community Health Centers in California but also support the construction of the new centers.

  More doctors where people need them

  Beginning October 1, 2010, the Act will provide funding for the National Health Service Corps ($1.5 billion over 5 years) for scholarships to help the 1,049 Community Health Centers in California but also support the construction of new centers and loan repayments for doctors, nurses and other health care providers who work in areas with a shortage of health professionals. This will help the 9% of California’s population who live in an underserved area.

  New Medicaid options for states

  For the first time, California has the option of Federal Medicaid funding for coverage for all low-income populations, irrespective of age, disability, or family status. For more information on health care reform issues visit: www.healthcare.gov.

  Also see our article, What Does Health Care Reform Mean for Beneficiaries? Summary of Key Provisions.

• 03Aug

  CMS Sends Drug Manufacturer Agreements for Coverage Gap 50% Discount Program

  Health Care Reform, Prescription drugs 1 Comment

  The Centers for Medicare and Medicaid Services (CMS) sent agreements to drug manufacturers yesterday about the 50% brand name drug discounts they’ll be offering next year to beneficiaries in the coverage gap, as part of the Affordable Care Act signed by the President in March. Drug manufacturers must sign the agreement by Sept. 1 in order to continue offering drugs through the Medicare Part D program. The agreement also outlines a dispute resolution and appeals process to be used for payment discrepancies or conflicts raised by the manufacturers. In addition, CMS will be conducting extensive editing on payment data to make sure beneficiaries receive their entitled discounts.

  See CMS’ press release for more information.

  For more information on health care reform and Medicare, see our article, What Does Health Care Reform Mean for Medicare Beneficiaries? Summary of Key Provisions.

  For more information on Part D, see our section Prescription Drugs.

• 30Jul

  Senate Prohibits Payment to Delay Generics

  Prescription drugs No Comments

  A Senate panel approved legislation to prohibit drug companies from paying generic drug makers to delay bringing less costly products to market. This marks a major defeat for the powerful drug lobby.

  The Senate Appropriations Committee approved the measure, which was inserted into a spending bill that funds the Federal Trade Commission’s budget. The measure would ban a “pay-to-delay” practice — opposed by the FTC in a series of lawsuits brought since 2001 — in which brand-name drug companies and generic drug makers both profit. Brand-name drug makers get higher prices while the generic companies are paid to stay out of the market.

  The provision was authored by Sen. Herb Kohl, D-Wis., with support from Dick Durbin, D-Ill., the No. 2 Democrat in the Senate and the chief author of the underlying spending bill.

  The vote was tight, first deadlocking 15-15 on an amendment by Sen. Arlen Specter, D-Pa., to strip the provision. Four Democrats voted with the drug lobby, and the drug company lobbyists thought they had the vote won, provided they could win over every panel Republican.

  Yet, Sen. Richard Shelby, R-Ala., voted against the drug companies, helping give Kohl and Durbin a surprise win. With health care costs spiraling up, Senator Kohl said “we cannot turn a blind eye to these anti-competitive backroom deals that deny consumers access to affordable generic drugs.”

  The FTC estimates that pay-to-delay deals cost consumers $3.5 billion a year. The agency suspects branded and generic drug companies made 21 such deals since last October. It would also save the government $2.6 billion over the next decade by reducing drug costs.

  FTC Chairman Jon Leibowitz attended the panel session and cheered the vote.

  The spending bill containing this provision has yet to advance to either the House or Senate floors and the drug lobby will be continuing their battle. To encourage the passage of this provision that can save consumers billions on prescription drugs, contact your Congress people.

• 01Jul

  Obama Holds Tele-Town Hall Meeting to Discuss Health Reform with Seniors

  Health Care Reform, Low-income help, Medicare Advantage, Medicare and other health insurance, Medicare basics, Prescription drugs No Comments

  Early last month, President Obama hosted a ‘tele’-town hall meeting for Medicare beneficiaries about the Affordable Care Act and Medicare fraud prevention efforts in light of the first $250 donut hole rebate checks that were sent out mid June. This meeting can be viewed online at whitehouse.gov.

  In this video, President Obama discusses the following topics:

  (Note: By clicking on a linked question, it will take you directly to that section of the video.)

  • Why does it take 10 years to close the doughnut hole completely?
  • Will Medicare Advantage changes hurt benefits?
  • Is there more support for primary care?
  • How does reform affect living independently vs in a nursing home?
  • Are Medicare & Social Security going to run out of money for future generations?
  • What’s going to happen to COBRA subsidies?

  For more information on health care reform and Medicare, see our article, What Does Health Reform Mean for Medicare Beneficiaries? Summary of Key Provisions.

• 06May

  CMS Terminates Western Health Advantage’s Medicare Contract

  Medicare Advantage, Medicare fraud, Prescription drugs No Comments

  During our California Medicare Coalition statewide call yesterday, a representative from the Centers for Medicare and Medicaid Region IX office announced that CMS is terminating its contract with the Western Health Advantage plan as of May 31, 2010. This will affect about 600 Medicare beneficiaries in Sacramento, Yolo and Placer counties. These beneficiaries will be automatically enrolled into Humana’s Part D prescription drug plan as of June 1st. They will also be given a 30-day Special Election Period (SEP) to enroll into a different plan by July 31, 2010.

  CMS sent out a letter to affected enrollees this week with this information, and advised them to call 1-800 Medicare or their local Health Insurance Counseling and Advocacy Program (HICAP) with any questions.

  Julie Cohen at CMS Region IX is overseeing this transition. Advocates with client questions can contact her at julie.cohen(at)cms.hhs.gov.

• 10Apr

  Medicare Issues Sanction Notice to Aetna Insurance Company

  Medicare Advantage, Prescription drugs 2 Comments

  Last week Medicare issued an intermediate sanction notice to Aetna Insurance Company prohibiting any marketing or enrollment of new beneficiaries into their national Part D prescription drug stand-alone plan and their 25 Medicare Advantage Prescription Drug plans (MA-PDs) as of April 21, 2010.

  This sanction is in response to growing provider and beneficiary complaints of not being able to access their medications and having unnecessary obstacles and illegitimate denials for drugs for which they are entitled.

  The Centers for Medicare and Medicaid Services says the sanctions will stay in place until Aetna adequately demonstrates they have corrected these problems and that they will not re-occur. Aetna currently has 400,000 beneficiaries enrolled in their MA-PD plans, and 600,000 enrolled in their stand-alone PDP plan.

  Some of the obligations Aetna plans have failed to fulfill for their Medicare beneficiary enrollees as listed in CMS’ press release include:

  • Failing to meet Medicare’s transition requirements by ensuring that existing beneficiaries were able to continue to receive drugs they had been receiving in 2009 that were not on the plans’ formularies in 2010;
  • Improperly processing coverage determinations and expedited appeal requests in cases where delays would jeopardize the life or health of the enrollee;
  • Applying prior authorization (PA) and step therapy (ST) drug requirements that had not been approved by Medicare; and
  • Failing to take timely and proper steps to ensure that enrollees are eligible for the Part D low-income subsidy (LIS).

  If the situation fails to improve for Aetna’s enrollees, CMS has warned that Aetna Insurance Company could incur penalties and even termination of their Medicare contracts.

  In addition to Aetna, CHA has reports of potential problems with WellCare Part D plans – such as encountering prior authorization (PA) requests for certain drugs where in the past there had been none. If you or your clients encounter any such problems with WellCare or Aetna plans, please contact us and let us know.

• 10Mar

  Medicare Terminates Contract with Fox Insurance Company’s Part D Drug Plans

  Prescription drugs 2 Comments

  The Centers for Medicare & Medicaid Services (CMS) terminated its contract with Fox Insurance Company on Tuesday March 9. After an onsite review of the plan and its services, CMS determined that the plan lacked even the basic standards of care. Fox’s violations, including improperly denying its enrollees coverage of critical HIV, cancer and seizure medications, posed a significant threat to the health and safety of its enrollees. CMS’ termination of the contract was effective immediately.

  This termination will not impact drug access for the more than 123,000 Medicare beneficiaries enrolled in Fox plans. As of Tuesday March 9th, they can obtain their drugs through LI-NET, a program run by Medicare and administered by Humana, to ensure they receive their Medicare prescription drugs in a timely manner. Fox enrollees can choose a new Medicare Part D plan between now and May 1, 2010. Those who do not choose a new plan by then will be enrolled in one by Medicare.

  CMS will send letters to all previous Fox enrollees explaining their continued access to prescriptions, and advising them to call 1-800-MEDICARE or their local state health insurance assistance programs if they have questions (which is HICAP – the Health Insurance Counseling and  Advocacy Program –  here in California).

  During CMS’s onsite audit of Fox’s drug plans, they found Fox continuing to subject its enrollees to obstacles in getting needed and, in many cases, life–sustaining medicines, even after the enrollment and marketing sanctions CMS issued on the plan in late February. Fox enrollees were often required to have unnecessary and invasive medical procedures before being able to obtain their needed drugs.

  Some of the violations CMS found in its audit as stated in their press release this week include:

  • Failing to provide access to Medicare prescription drugs benefits by imposing unapproved prior authorization and step therapy criteria that made it more difficult for beneficiaries to get drugs that are protected by law.
  • Not meeting the plan’s appeals deadlines.
  • Not complying with Medicare regulations requiring enrollees to be transitioned to new drugs at the beginning of the new plan year.
  • Failing to notify enrollees about prior authorization and step therapy determinations as required by Medicare.  

  California beneficiaries who were enrolled in a Fox plan and who have any concerns with drug coverage access can call 1-800-MEDICARE (1-800-633-4227) or HICAP (1-800-434-0222) to help get them resolved.

  NOTE: States in which the Fox plan was available were: Arkansas, Arizona, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Louisiana, Maryland, Missouri, North Carolina, New Jersey, New York, Nevada, Ohio, Pennsylvania, South Carolina, Texas and West Virginia.

• 09Mar

  Retail Price for Some Drugs Is Cheaper Than Part D Plans

  Prescription drugs No Comments

  Some California beneficiaries have found lower prices for their prescription drugs in the open market than those negotiated by their Part D plan. Two such cases have recently been brought to our attention.

  One example is with a drug, Finasteride. A beneficiary found that it cost her 2.5 times more to get it in her Part D plan than at Costco. Therefore, she bought her prescription at Costco instead of using her Part D plan. Subsequently, what she spent at Costco was not counted toward her  TrOOP (true out-of-pocket expenses). In this case, it happened to be a plus for her since it delayed her entrance into the coverage gap, or donut hole.

  In another case, a beneficiary’s Part D plan drug copayment was higher than the retail price for the same drug outside the plan.

  We have notified the Centers for Medicare and Medicaid Services about this issue.  Yet, it’s unclear what CMS can do since the Medicare Modernization Act (MMA) of 2005 prohibits the federal government or the Secretary of Health and Human Services (HHS) from negotiating Part D drug prices.

  If you hear of additional cases like this, let us know. You can also contact your Congressional Representative or Senator to voice your concern on this issue.

• 29Dec

  New Fact Sheet Has Info on Drugs Not Found on Medicare’s Drug Plan Finder Tool

  Prescription drugs 1 Comment

  The Centers for Medicare and Medicaid Services (CMS) put together a 5-page fact sheet that answers frequently asked questions (FAQs) about medications that are often not found when researching drug plans on their Medicare Prescription Drug Plan Finder tool.

  See: Researching Drugs Fact Sheet (PDF)

• 02Sep

  Do State Unemployment Benefits Count as Income in Determining Eligibility for Part D Subsidy?

  Low-income help, Prescription drugs No Comments

  We recently had a good question come to our office regarding unemployment benefits and eligibility for the Part D low-income subsidy (LIS). Below is the question along with the short and long answer.

  1.      Does state unemployment benefits count as income for determining LIS eligibility?

   

  Short answer: state unemployment benefits count as income for LIS eligibility.

   

  Long answer: The definition of income for LIS is the same as for SSI, which is “any item an individual receives in cash or in-kind that can be used to meet his or her need for food or shelter.”  Items that fall into the definition can be excluded by statute.  Example, in-kind support is income, but MIPPA excludes it as countable income for LIS eligibility effective Jan 1, 2010.  State unemployment benefits fall into the definition of income and has not been excluded by statute, thus it is counted as income for LIS purposes.

  Question: Do state unemployment benefits count as income for determining LIS eligibility?

  Short answer: Yes, state unemployment benefits do count as income for LIS eligibility.

  Long answer: The definition of income for  the low-income subsidy is the same as for Supplemental Security Income (SSI), which is “any item an individual receives in cash or in-kind that can be used to meet his or her need for food or shelter.”  Items that fall into this definition can be excluded by statute.  For example, in-kind support is income, but the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) excludes it as countable income for LIS eligibility effective Jan 1, 2010.  State unemployment benefits fall into the definition of income and has not been excluded by statute, thus it is counted as income for LIS purposes.

  Click here for more general information on the Part D low-income subsidy.

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