CHA Blog

• 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 1 Comment

  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 2 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. 

« Previous Entries   Next Entries »