Medicare and Part D

New information available for
Medicare Part D beneficiaries

January 11, 2008

Discrepancies between information on the Medicare Plan Finder and information on the individual plan website or given out by plan customer service lines:

There is no blanket policy regarding information discrepancies between the Plan Finder and what plans say on their website or their customer service lines. However, Centers for Medicaid and Medicare Services (CMS) is willing to look at individual cases when someone gets coverage information (drugs being covered/not covered or utilization management requirements) that is different, especially if it leads to a bad plan choice.

In order to report this situation to CMS:

Beneficiaries: Should call 1-800-MEDICARE to file a complaint in the complaint tracking system. The Beneficiary should say they have a “complaint.” Using the actual language will help the representatives to understand how they should file it. The beneficiary should expect a call from the plan about a week after filing the complaint. They should follow up with 1-800-MEDICARE if they don’t receive a call from their plan.

Case Managers/People Helping Clients: Should have beneficiary file a complaint. If the case isn’t resolved, contact at Project Inform. Please state whether the beneficiary has filed a claim and if a response has been received. The following information is helpful (although not absolutely necessary: plan name and contract number, date the person looked at the Medicare plan finder and/or contacted the plan, the name of the drug, and nature of the information discrepancy. Pricing discrepancies are harder to resolve since drug pricing can change by the week.

Transitioning into a New Part D Plan:

Open enrollment period ended on December 31, 2007. People may have selected new plans or they may have been reassigned to a new plan for 2008. In California, slightly over 50% of our dual eligibles (have both Medi-Cal and Medicare) have been reassigned. Here are some tips from CMS for assisting those who are moving to new plans:

Pharmacy Counter Tips
If a person with Medicare needs a prescription filled before they have received their new plan ID card, they can bring other items with them to the pharmacy to assure they will be able to get the medicines they need. A new tip sheet, Quick Tips for People with Medicare: Using Your New Medicare Drug Coverage is available in English and Spanish. In addition to the tips included in the sheet, people with HIV should always check to see if their state AIDS Drug Assistance Program can cover their prescription needs if they are unable to get their medications through their Medicare Part D plan.

In addition, WellPoint Next Rx should work as a back up plan for people with Medicare who also have Medicaid (dually eligible) or have qualified for extra help (Low Income Subsidy), but aren't enrolled in a Medicare drug plan. A CMS tip sheet, “Information Partners Can Use on: The Point-of-Sale Facilitated Enrollment Process” should be available in the future.

If a beneficiary, is dually eligible or has extra help and is not enrolled in a plan, they should ask their pharmacist to invoke the WellPoint option for immediate coverage. The most likely time for WellPoint to work is when someone already has Medicaid and has newly qualified for Medicare but not yet enrolled in a Part D plan.

Filing a Grievance, Requesting a Coverage Determination:

CMS has a publication entitled “Medicare Prescription Drug Coverage: How to File a Grievance, Request a Coverage Determination or File an Appeal.” It is available in English and Spanish. Beneficiaries can file an urgent coverage determination if they can’t get an important medication. The plan must respond within 24 hours when it receives the request for an expedited coverage determination. The plan may ask a doctor to confirm the urgency. It is important to use the words “urgent” or “expedited” when filing the coverage determination. The beneficiary should call 1-800-MEDICARE if the plan doesn’t respond within 24 hours and file a complaint. If someone still is having trouble getting a necessary medication, they should contact an advocate for assistance. The plans have longer for a standard coverage determination. This publication also covers how to file a grievance.

Medicare Part D Complaints:

A publication called “Handling Medicare Part D Prescription Drug Plan Complaints” is available. This is a good tip sheet to read before dealing with plans on any complaints.

Repayment of Premiums and Copayments
That Have Been Paid by the Beneficiary:

Another publication covers how to deal with repayment for out of pocket expenses that should have been covered by Medicare. The title is Information Partners Can Use on Repayment of Premiums and Copayments Paid Out-of-Pocket.