Medicare and Part D

Model Type

Section &/or Para.

Description of Issue or Problem

Suggested Revisions or Comment

Throughout – all plans

Beneficiaries are repeatedly referred to websites and customer service representatives for formulary and provider information.

Plans should be required to make formulary and provider information available in hard copy, and not just on the Internet or through customer service centers. The overwhelming majority of Medicare beneficiaries, and in particular low-income beneficiaries, do not have access to or use the Internet for health information. Plan customer services lines also are not helpful. Our experience is that when advocates, beneficiaries, and physicians contact plan customer service representatives to get information about utilization management requirements, they are given incorrect information, even after advocates complain to CMS about such problems.

Throughout – all plans

Telephone numbers are not always provided when beneficiaries are told to contact plans or other entities.

Plans should be required to include their telephone number every time beneficiaries are advised to contact the plan directly for more information. Telephone numbers should also be included whenever a beneficiary is told to contact another entity, for example, an SPAP, state Medicaid agency, Social Security Administration, ADAP, SHIP, etc.

All plan types

Entire model, Info. related to costs for persons with LIS

Document fails to contain individualized information on 2008 plan costs and how they will differ from 2007 for persons with LIS. Chart in ANOC (What do I need to know if I qualify for Extra Help”) is too general because it requires persons to know or find out what level of Extra Help they have to see what premiums and cost-sharing they will pay. For more information on LIS costs, ANOC refers reader to the EOC, Sec. 5 but plans may wait to send the EOC until January, 2008. Even if the plan uses a unified ANOC/EOC, Section 5 of the EOC does not contain personalized cost information and refers the person to the LIS Rider, without indicating whether the LIS rider applies to the reader, or indicating where in the mailing the Rider can be found. While the LIS Rider is required to be personalized, it may not be sent with the ANOC if the plan chooses to send the EOC separately.

ANOC/EOC should have individualized costs for persons with LIS. If documents are not individualized, LIS Rider must be sent with the ANOC. Whenever plans send the LIS Rider, plans should clearly indicate it applies to the recipient and make it prominent in the mailing.

MA-PDs and PDPs /ANOC

p. 5

Note re separate mailing of EOC.

January 31 is too late for mailing the EOC. It leaves beneficiaries without plan information for more than a month. CMS should require that the document be sent within the first week of January.

MA-PDs and PDPs

ANOC, p. 5
How will my prescription drug coverage costs change?

Information about cost changes is not personalized. Persons must reference the formulary, which does not highlight changes from 2007 to 2008.

Information about drug cost changes should be personalized. Alternatively, formulary must highlight and compare how costs and utilization techniques will change from 2007 to 2008.

MA-PDs and PDPs

ANOC, p. 6. How will my prescription drug coverage costs change?

Language, “If you received approval for a formulary or tiering exception request during the 2007 plan year, coverage for the drug approved under the approved exception will end on December 31, 2007” is only mandatory if the plan has not otherwise informed the consumer of this elsewhere writing. Also, many readers may not understand the terms “formulary or tiering exception request.”

Language should be mandatory in all ANOCs since the ANOC reflects how benefits will change for 2008 and this is critical information about how the reader’s costs may change. Also, health literacy and outreach studies show repetition is essential for persons to understand and act upon information, especially if was received several months ago. “Appeal” rather than “formulary or tiering exception request” should be used because it’s easier to understand.

MA-PDs and PDPs

ANOC, p. 7. What if my drug is no longer on the formulary or is in a more expensive cost-sharing tier?

Only mentions the possibility of an exception if no alternative on the formulary.

Possibility of filing an appeal should be mentioned, because appeal rights apply even if there is an alternative on the formulary.

All Plans

ANOC throughout

The ANOC makes several references to the Summary of Benefits. The draft contains no model summary. The draft also allows the summary to include multiple plans provided by a single sponsor.

Without seeing what is required for a summary of benefits, it is difficult to comment on its usefulness. Moreover, a summary should only cover the one plan in which the beneficiary is enrolled. A broader summary adds more complexity to what the beneficiary must sort through and also could function as a marketing tool for one plan sponsor’s plans. This is inappropriate for the important educational function of the ANOC mailing.

SNPs

Multiple locations: ANOC, EOC - How You Get Care p. 28; Summary of Benefits; Your Costs for this Plan

These sections fail to require dual eligible SNPs to indicate how the state Medicaid program will supplement Medicare benefits or to indicate what co-pays or premiums persons with Medicaid (including the Medicare Savings Programs) will pay for medical benefits. They also fail to require all SNPs to indicate which of their network providers may not serve all categories of enrollees.

Dual eligible SNPs must be required to specifically delineate how Medicaid will coordinate with and supplement Medicare benefits since SNPs are supposed to coordinate and manage care for dual eligibles. Omitting this information severely hampers the ability of this very vulnerable population to understand how their health care works and know their overall health care costs as a member of that plan. D-SNPs should also indicate which of their providers are not Medicaid providers. Institutionalized SNPs that serve beneficiaries who receive an institutionalized level of care in the community should indicate which of their physicians and other network providers do not serve people in the community.

All plans

EOC p. 16

Contact information is listed for “Organizational determinations”, “Part C Determinations”, etc.

Contact listings should include consumer friendly terminology. Beneficiaries are unlikely to know what an “organizational determination” is or what a Part C determination covers.

SNPs

EOC p. 18

Current note states SNPs “may” provide Medicaid contact numbers for program assistance.

SNPs should be required to include Medicaid contact numbers for dual eligible SNPs. This would be more appropriately located on p. 19. Institutional SNPs should provide Ombudsman numbers. This should be a separately highlighted section and not subsumed under SHIPs.

MA-PDs and PDPs

EOC p. 19

Social Security.

Add a sentence saying that Social Security is the agency where beneficiaries can apply for “extra help” with Part D costs.

MA-PDs and PDPs

EOC p. 20; Welcome

The document welcomes the beneficiary to the plan and thanks the beneficiary for ‘choosing’ the plan. The beneficiary has not yet chosen the plan for 2008. Including language like this will make it hard for the beneficiaries to understand that they can still change plans for 2008.

Do not combine the ANOC with the EOC. If the documents are combined, make sure it is clear that the benefits described will apply if the beneficiary does not exercise her right to change plans.

All plans

EOC p. 21

Notice of availability of information in different languages and formats.

This notice is very unhelpful in its current location, which is extremely difficult to find. It should be prominently placed, in appropriate languages, in the front of all important documents. Moreover, information should be available in all major languages, not just Spanish.

EOC p.22

Reference to Medicare Savings Plans.

Many beneficiaries may be unfamiliar with the term, Medicare Savings Plans. Specific program names should also be listed. Also, the text refers readers to section 1, but there is no mention of Medicare Savings Plans in Section 1. This section should also mention the Low Income Subsidy.

MA-PDs and PDPs

EOC p.22

Instructions for using plan ID card.

A sentence should be added to discuss the best available evidence policy, telling beneficiaries that, if they have recently enrolled in the plan and they have not yet received their ID card, they can bring a letter from the plan or other evidence to show the pharmacist.

MA-PDs and PDPs

EOC p. 24

Explanation of Benefits.

This section does not explain to LIS beneficiaries, particularly duals, what parts of the EOB do not apply to them. Add an explanation.

PDPs

EOC p. 27 and table of contents

Title of Section 2.

If the plan is a PDP, change the heading for Section 2 to “ How you get prescription drugs”.

PFFS plans

EOC p. 30 and throughout

The first sentence “You may get services from any provider in the United States eligible to participate in the Medicare program,” is misleading and falls well short of CMS’ new marketing requirements which require plans to include a disclaimer anytime they claim that a beneficiary can see any provider.

Bring the sentence into compliance with CMS’ own marketing guidance by adding to that sentence “who agrees to accept our terms and conditions of payment.” Materials form PFFS plans must also include the disclaimer required by Abby Block’s May 25th letter to plans.

A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital must agree to accept the plan’s terms and conditions prior to providing healthcare services to you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. Providers can find the plan’s terms and conditions on our website at: [insert link to PFFS terms and conditions].

PFFS plans

EOC p. 23, Provider director section, And How You Get Care, p. 28 (PFFS plans)

The directory section states that the directory lists the names of providers who have entered into a written contract with the plan and that beneficiaries may pay more if they do not use a network provider. The PFFS plans sections define a plan provider as someone who agrees to provide you with plan-covered services and does not say that a provider can change his/her mind about accepting the plan’s terms and conditions

The model fails to explain that providers do not have to accept the PFFS plan

PFFS enrollees encounter significant provider access problems. This section fails to inform beneficiaries that providers can decide, on a per episode basis, not to provide them with services, even when the same providers used to provide the beneficiaries with care. Failing to include this explanation gives enrollees a false sense that, by paying more for services, they will continue to be able to see any doctor who is enrolled in Medicare.

Network plans

EOC p. 32 How do you get care from doctors, specialists and hospitals?

The note about follow-up specialty care should be highlighted.

In our experience beneficiaries who have been referred to a specialist assume that the referral encompasses specialist recommended follow-up care. The need to get referrals should therefore be highlighted.

PFFS plans

EOC pp. 31-32 How to get care from doctors, etc

The section is inconsistent. The first paragraph does not state that the plan will provide a written advance coverage determination, but the third paragraph says that the law gives you the right to a written coverage determination.

Modify the first paragraph to say written coverage determination.

All plan types except PDPs

EOC p. 39, Hospital care, SNF care, and other services

The definitions are incorrect and confusing. They do not indicate that a beneficiary can begin a new benefit period after a 60-day institutional stay at a less-than-Medicare covered level of care.

The definitions also do not indicate that the concept of benefit period is irrelevant for most MA plans, since most of them charge a daily rate per each hospital stay.

Clarify that a new benefit period may begin after a 60-day institutional stay at a less than Medicare-covered level of care. Eliminated the last two paragraphs of the definition in the definition section.

Require plans the impose a daily co-payment for in-patient care for each hospital or SNF stay to so indicate. The concept of benefit period does not apply in these plans. For example, some plans charge a $200/day co-payment for in-patient care.

PDPs and MA-PDs

EOC p. 46, Medicare and Medicaid

This section fails to inform beneficiaries of the benefits of the LIS.

Include information about deeming and LIS benefits.

PDPs and MA-PDs

EOC p. 49 Using plan pharmacies to get prescription drugs-Filling prescriptions outside the network—how to submit a paper claim

This section fails to provide sufficient information about seeking reimbursement when a beneficiary must use a non-network pharmacy.

Require plans to provide the contact phone number and address, and the information to be provided, in order to get reimbursed.

MA-PDs and PDPs

EOC p. 49

Last sentence on page—wrong reference.

This sentence refers beneficiaries to Section 6 for information on coverage determinations but they should be referred instead to Section 10.

PDPs and MA-PDs

EOC p. 50, How does your prescription drug coverage work if you go to a hospital or SNF

This section only discusses what happens when a beneficiary is admitted. It fails to discuss procedures for out-patient services or when a beneficiary is otherwise in a Part B-covered hospital stay.

Describe that Part D plans pay for drugs when the hospitalization is not covered under Part A. Explain that many hospital pharmacies are not network pharmacies and provide information about seeking reimbursement if the hospital pharmacy is not a network pharmacy.

All plans except PDPs

EOC p. 66 Benefits chart – vision care

The discussion is not clear.

Clarify the kinds of eyeglasses or contact lenses to be provided after cataract surgery. Must these also be corrective lenses?

PDPs

EOC p. 71, Transition policy

The section is not clear on how enrollees will be provided notice of their transition rights and to call the plan.

Explain in greater detail the right to receive a transition fill and a written notice when a transition fill is provided that explains the need to contact the plan for an exception before the transition period expires.

PDPs and MA-PDs

EOC p. 72 Drug management programs

The web-site formulary and customer service line should not be the only way to find out that a drug is subject to utilization management.

The section should not be optional for PPFS plans that provide drug coverage.

The section fails to inform beneficiaries that they need the assistance of a physician to request an exception.

The section fails to clarify the distinction between prior authorization and other utilization management requirements.

The section fails to explain that some drugs may be subject to prior authorization because they may be covered under Part B.

This section fails to provide beneficiaries with adequate information about plan formularies and about appeal rights.

All plans that provide drug coverage, including PFFS plans, should be required to include utilization management requirements in a printed formulary that is given to all members.

The section should state in bold that a physician must request an exception and a copy of the model exception request form should be included.

Plans should be required to indicate whether they use the term prior authorization to cover all utilization management requirements or whether they have a separate category for prior authorization. They should also be required to indicate ALL utilization management requirements for a particular drug, ex. prior authorization and quantity limits, or step therapy and quantity limits.

The section should also explain that some drugs may be subject to prior authorization to determine whether they will be paid for under Part B.

PDPs and MA-PDPs

EOC p. 73 Medication Therapy management programs

This section is optional for PFFS plans.

PFFS plans that offer drug coverage should be required to include the information.

PDPs and MA-PDPs

EOC p. 75, Your costs for this plan

This section contains only minimal information about what individuals with the LIS will pay. Most of the information in this section will apply differently or not at all to LIS recipients. They should not be given information about non-LIS premiums, cost-sharing and coverage gaps.

LIS recipients account for 40% of all Medicare Part D enrollees. This information should be tailored to them.

All plan types except PDPs

EOC p. 75, Your costs for this plan

The note: Cost plans cannot offer Part B premium reductions.

This note is confusing. If it is meant for cost plan sponsors, then those sponsors should be told not to include statements about Part B premium reduction in the material sent to beneficiaries.

PDPs and MA-PDs

EOC p. 77, Paying the premium

This section does not caution about delays in premium withdrawals when choosing the Social Security withdrawal option.

A note should be added about delays in having premiums withdrawn from a Social Security check, and that Social Security may not begin withdrawal in the first month of enrollment, but two months premiums may be withdrawn subsequently.

PDPs and MA-PDs

EOC p. 78, Can your premium change during the year

The section fails to describe the procedure for retroactive premium payment if someone is found eligible for LIS retroactively.

The section should state that if someone is found eligible for LIS retroactively the plan must return the premiums already paid for that period and describe the procedure for getting reimbursed.

PDPs and MA-PDs

EOC p. 81 How much do you pay for drug covered by this plan

The chart for the initial coverage period is very confusing. It should also reinforce that it applies only to drugs covered by the plan.

Simplify the chart.

Change the title to read “You will pay the following for your prescription drugs covered by this plan.”

Add a note that a beneficiary may request an exception to request a lower cost-sharing amount.

PDPs and MA-PDs

EOC p. 83 Vaccines

The chart is very unclear.

Define administration of a drug and explain that Medicare pays separately for the drug and for administration and that in certain situations a beneficiary may have to pay separate cost sharing.

Distinguish more clearly in the chart the cost-sharing for the drug and for administration.

PDPs and MA-PDs

EOC p. 84, How is your out-of-pocket cost calculated, and Who Can pay for your prescription drugs

The sections do not adequately distinguish between payments that do and do not count towards TrOOP.

Change the format so that the sentence “Purchases that won’t count toward your out-of-pocket costs:” is in a larger font so that it stands out.

In the second section eliminate the bullet before “payments made by the following don’t count toward your out-of-pocket costs” and make it a separate paragraph.

Add a bullet for Aids Drug Assistance Programs (ADAPs) under the payments that do not count.

PDPs and MA-PDs

EOC p. 86
Best Available Evidence

If each plan has a process and timeline for best available evidence, why has this not been shared publicly before?

Require all plans to include this process in the EOC and post it to their websites so that advocates, pharmacists and SHIP counselors have access to it.

PDPs and MA-PDs

EOC p. 93-99

Where appropriate, the rights and responsibilities must also apply to access drug coverage.

A section for PDPs must be added to the following rights:
- Your right to see plan providers…get your prescriptions filled, etc.
- Your right to know your treatment choices and participate in decisions about your health care
- Your right to get information about our plan, your drug coverage and costs.

All MA plan types

EOC p. 101, General exclusions

The dental care exclusion, number 14, is overly broad.

Non-routine, as opposed to “certain,” dental services received at not only a hospital, but also in a dental office, may be covered. Whether services are covered does not depend on where they are received.

MA plans (p. 16) and PDPs and all other plan types with Rx (p. 123)

Part C grievances and What to do if you have complaints about your Part D prescription drug benefits

Throughout, grievances are discussed before coverage determinations and contacts for grievances are listed before contacts for coverage determinations.

Plans should be required to accept requests for organization determinations and coverage determinations in all modes of communication to ensure that beneficiary rights are protected. Toll free call center numbers should be required of plans

.

Organization determinations Part C) and coverage determinations (Part D) can be critical to health outcomes for beneficiaries. They should be given priority to grievances throughout the EOC. Their contact numbers and their descriptions should be listed first.

Additionally, fax numbers should be required, not be optional, since plans often want requests and supporting information faxed to them in expedited cases.

Plans should be required to accept email requests and to have a toll free phone number for their coverage determination/organization determination/appeals line, as well as for call centers.

PDPs and all other plans types w/RX

EOC p. 125-126 What is an exception

The section fails to address prior authorizations and to explain the relationship between an exception and a prior authorization request.

A paragraph should be added that describes each plan’s prior authorization process and how to get a plan’s prior authorization requirements and criteria. The paragraph should explain whether the plan requires both prior authorization and other utilization management requirements for certain drugs.

A second paragraph should be added to describe the relationship between prior authorization and exceptions. Plans should be required to indicate whether a prior authorization request that is granted remains in effect for the remainder of the plan year, as does an exception, or whether the plan permits limitations on the length of prior authorization requests.

PDPs and all plans with Rx

EOC p. 127 Asking for a fast decision

EOC p. 131
Asking for a fast appeal

Plans should not be given the option of specifying different “instructions for delivering requests that are made outside of regular weekday business hours if the plan has a different process for doing so.”s

Beneficiaries and their health care providers need simplicity and accessibility when they urgently seek approval for medical procedures and prescription drugs. They should not be confronted with multiple contact numbers depending on the day of the week or the time of day. Health care providers already must contend with keeping track of a large number of contact information, given the large number of PDPs and MA-PDs in each region of the country. This provision might result in the doubling or even tripling of the numbers a health care provider may be required to use.

All plan types except Cost Plans

EOC p. 139, Voluntarily ending your membership

The continuous SEP for LIS eligibles should be noted in this section. For 40% of Part D enrollees, the opportunity to change plans at any time is an important right.

A new third paragraph should be added saying “If you receive ‘extra help’ you can change plans at any time. The change will be effective the first day of the month after you submit your enrollment request.”