CHA Blog

• 10Mar

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

  Prescription drugs No 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.

• 20Aug

  Medicare Part D Costs for 2010

  Prescription drugs 1 Comment

  Below is a summary of Medicare’s Part D prescription drug program costs for 2010.

  See our Prescription Drugs section for more information on Medicare Part D.

  For the ’standard’ Part D plan:

  • Annual Deductible: $310 (Beneficiaries who do not qualify for the low-income subsidy (LIS) must pay 100% of drug costs until they reach the deductible)
  • Initial Coverage Period: drug costs between $310-$2,830 (Beneficiaries must pay 25% of their drug costs, which is $630, and their Part D plan pays the other 75%)
  • Coverage Gap – Donut Hole: drug costs between $2,830 – $6,440 (Beneficiaries pay 100% of their drug costs, totaling $3,610)
  • Catastrophic Coverage: drug costs >$6,440 (Beneficiaries pay the greater of either 5% of their drug costs or a copayment of $2.50 for generics and $6.30 for brand name drugs; their Part D plan pays the other 95%)

  The total true out-of-pocket (TrOOP) costs before catastrophic coverage kicks in for 2010 is $4,550 ($310 + $630 + $3,610)

  People who qualify for the full low-income subsidy (LIS) will have drug copayments of $1.10 and $3.30 for generics and brand name drugs respectively. People who qualify for the partial LIS will have copayments of $2.50 for generics and $6.30 for brand name drugs.

  The national average premium for 2010 is $31.94.

  The California benchmark plan premium is $28.99. Benchmark plans are Part D plans with monthly premiums below the California average. Beneficiaries who qualify and have the full LIS do not pay a premium or deductible if they enroll in a benchmark plan; they are, however, still responsible for paying their drug copayments. 

  Beneficiaries with the LIS who enroll in a Part D plan with premiums higher than the benchmark must pay the difference between the subsidy ($28.99 in 2010) and the plan’s premium.

   

  Basic Medicare Part D plans with monthly premiums below the California average are referred to as benchmark plans. The premium for these plans in California is $24.86 in 2009. The full Low-Income Subsidy (LIS) program covers the premium and deductible of benchmark plans. This means you do not pay a premium or deductible if you receive the full LIS benefit and enroll in a benchmark plan. You are, however, still responsible for copayments of $1.10-$6 for each covered prescription.

  If you enroll in a Medicare Part D plan with premiums higher than the benchmark, you will pay the difference between the subsidy ($24.86) and the plan’s premium.

  See our section on Prescription Drugs for more info.

• 09Jul

  Learn What Drugs Are Covered Under Medicare Parts A, B, and D

  Medicare basics, Prescription drugs No Comments

  The Centers for Medicare and Medicaid Services (CMS) recently revised their tip sheet explaining what prescription drugs are covered under Medicare Part A (hospital insurance), Medicare Part B (medical insurance), and Medicare Part D (prescription drug coverage). 

  If you or your clients have questions about which part of Medicare covers what drugs, this is a good place to start.

  In general, Part A only covers drugs that are administered as part of a beneficiary’s treatment while in a hospital or skilled nursing facility. Part B generally covers drugs that aren’t normally self-administered and instead are given as part of a doctor’s service. Coverage is usually limited to drugs that are given by infusion or injection. If the injection is self-administered or isn’t given as part of a doctor’s service, Part B generally won’t cover it.

  Part B also covers several other drugs, including: 

  • Various vaccination shots (flu shot, pneumococcal shot, Hepatitis B shot)
  • Some drugs used in infusion pumps and nebulizers
  • Osteoporosis drugs
  • Immunosuppressant drugs
  • Some oral anti-cancer drugs

  For a complete listing and explanation, see the CMS tip sheet.

  Part D provides comprehensive coverage for many generic and brand-name drugs and is offered through private Part D prescription drug plans. All Medicare drug plans must generally cover at least 2 drugs in each drug category, yet they can choose which 2 drugs to cover. In 6 drug categories, however, Medicare drug plans are required to cover all drugs. These 6 categories include: antidepressants, antipsychotics, anticonvulsants (drugs toprevent seizures), antiretrovirals (drugs to treat HIV/AIDS), immunosuppressants, and antineoplastics (anti-cancer drugs).

  Part D also covers most vaccination shots (except those covered under Part B).

  Medicare Part D does not cover drugs that are covered under Medicare Parts A and B. It also doesn’t cover the following drugs:

  • Benzodiazepines
  • Barbiturates
  • Drugs for weight loss or gain
  • Drugs for erectile dysfunction
  • Drugs for relief of cough and colds
  • Non-prescription drugs
  • Drugs used for cosmetic purposes or hair growth
  • Drugs used to promote fertility
  • Prescription vitamins and minerals, except prenatal vitamins and fluoride preparation products

  See the tip sheet, Medicare Drug Coverage under Medicare Part A, Part B and Part D, for more information. 

  See our section on Medicare Appeals for information on your appeal rights and how to file an appeal for drugs if coverage is denied. 

  For information on basic coverage under Medicare Parts A, B, and D, see our section Medicare Basics. 
• 27Apr

  More Beneficiaries in MA plans Will Qualify for Free Pharmacy Consultation Services in 2010

  Medicare Advantage, Prescription drugs 1 Comment

  Currently, Medicare Advantage (MA) beneficiaries with at least $4,000 worth of annual drug costs are eligible for pharmacy consultations at no cost. These consultations are provided to ensure: 1) people understand how to use their medication, and 2) the medication prescribed will not produce adverse side-effects with other medications the person may be taking.

  In 2010, new guidelines from the Center for Medicare and Medicaid Services (CMS) will broaden the pharmacy consultation benefit to more MA beneficiaries. Health plans will be prohibited from restricting access to the benefit to members with a high number of chronic health conditions and medications, and the annual drug cost limit will be reduced from $4,000 to $3,000. Also, under the revised guidelines, MA plans will be required to review their member rolls on a quarterly basis to identify eligible members for the program. 

  Pharmacists will be paid $50 by the health plans to review a beneficiary’s medications and make recommendations to their physician. Pharmacists will receive additional payments if they recommend a less-costly, therapeutic equivalent to the patient. This may be an important step, both in reducing health care costs and in improving people’s overall health as less medications reduce side effects and harmful interactions between medications.

  For information on Medicare’s Part D drug coverage, see:

  • Prescription Drugs – Medicare Part D
• 12Mar

  Got Complaints About the National Shortage of Generic High Blood Pressure Medication?

  Prescription drugs Comments Off

  Have you heard complaints that prescriptions for metoprolol succinate ER, one of the generic versions of the beta blocker medication Toprol XL, can’t be filled due to a national shortage of the drugs? Since late last year, our country’s two biggest suppliers of this commonly used generic high blood pressure medication have slowed production to almost a halt. Novartis’s generics unit, Sandoz, recalled 6 million bottles of generic Toprol XL late last year, after the FDA sent the company a warning letter about the factory in North Carolina that makes the pills. Another supplier, KV Pharmaceutical, is experiencing economic challenges and has said it would stop making and selling all of its products, including generic Toprol XL.

  Most Medicare Part D plans cover the generic version of this drug, which is cheaper for beneficiaries to use. Now, however, when local pharmacies are unable to refill prescriptions for the generic version, they call the beneficiaries’ doctors to change the prescriptions. If the prescription is changed to the brand name, the drug is either on a higher cost-sharing tier or it’s not on the formulary at all.

  Advocates are receiving complaints from beneficiaries about:

  1. having to pay more money for the brand name version of the beta blocker;
  2. not having enough money to pay for the brand name drug; or
  3. having to file an appeal to receive a version of this drug that’s not on their plan formulary.

  Advocates have asked the Centers for Medicare and Medicaid Services (CMS) to issue plan guidance requiring them to cover the brand name version of the beta blocker until the shortage is resolved. CMS is currently following up on the drug shortage status. In the meantime, if you have any additional beneficiary/client complaints, stories or experiences around this issue, please share them with us and we will forward your complaints to CMS.

  Here’s an article in the Wall Street Journal discussing the cause of the shortage.

  For more information on Part D and/or appeals, see:

  • Prescription Drugs
  • Medicare Part D Appeals
• 07Jan

  New Marketing Rules Fail to Cure Problems in the Medicare Marketplace

  Medicare Advantage, Prescription drugs No Comments

  We recently published an issue brief exploring how the new marketing rules for the sale of Medicare Part C and D plans have failed to cure the problems in Medicare’s marketplace. 

  Even though, Congress and the Centers for Medicare and Medicaid Services (CMS) have made progress in their recognition of and efforts to address marketing misconduct in the Medicare marketplace, many problems persist. This year Congress passed the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and CMS has issued implementing regulations and clarifying guidance. Many of the statutory and regulatory changes do improve beneficiary protections, but they also have some significant loopholes and/or exceptions, and it is yet unclear how some of the rules will be implemented. Some of these new rules are codifications of existing rules (e.g. a prohibition on unsolicited door-to-door marketing) that, in the view of those assisting Medicare beneficiaries, have been widely flaunted. Although the new rules will help, this issue brief points out how and why marketing misconduct continues. It discusses some ongoing systemic barriers to adequate oversight of the Medicare marketplace, such as the federal preemption that still plagues the regulation of Medicare Advantage and Part D plans by hindering or even preventing action at the state level, and the sporadic oversight and enforcement actions at the federal level.

  This brief also reviews some of the changes in marketing rules implemented in 2008 by identifying strengths, weaknesses, and room for improvement. The brief is organized as follows:

  • Part I provides a short overview of regulation changes to the Medicare marketplace in the last couple of years;
  • Part II explores unresolved systemic issues that prevent adequate oversight of marketing in the Medicare marketplace;
  • Part III analyzes selected new marketing rules, including their shortcomings;
  • Part IV provides recommendations to better protect consumers from marketing abuses;
  • Appendix 1: is an update on Medicare Advantage “Gap” Plans (following-up on an issue brief on the subject drafted by California Health Advocates in November 2007), along with a couple of examples of ongoing marketing of these products to agents; and
  • Appendices 2 and 3 are examples of marketing documents referenced in the text.

  View the full issue brief (pdf).

  Also, learn more about Medicare Advantage plans and Medicare Part D plans.

• 01Jan

  CHA Comments on CMS’ Proposed Rules on New Compensation Limits for Agents Selling Medicare Part C & D Plans

  Medicare Advantage, Prescription drugs Comments Off

  CHA recently submitted comments drafted jointly with various advocacy organizations on the Center for Medicare and Medicaid Services’ (CMS) proposed rules. The comments reveal how proposed compensation rules actually encourage unsuitable Medicare Advantage enrollments. This is because, under the current rules, commissions are nearly double for enrolling beneficiaries new to Medicare Advantage versus commissions for people staying in their current plans or switching to a similar MA plan. The rules encourage agents to focus enrollment efforts on people new to Medicare, or those in Original fee-for-service Medicare who have a Medicare supplement plan (Medigap), Medi-Cal, or employer or retirement coverage. This poses a problem because it is precisely these beneficiaries—those who are accustomed to the wide provider access, protection against catastrophic expenses and predictable monthly expenses of a Medigap supplemental plan, who may have all Medicare cost-sharing and additional benefits paid by Medicaid, or who stand to lose supplemental coverage from a former employer —for whom a Medicare Advantage plan is often unsuitable. 

  The comments include several recommended changes to these rules and agent compensation structures.

  View full comments.

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