Practice Manager Insider

CMS Reports Last-Minute Stampede to Join Part D

The final day of the first 6-month window to enroll in Medicare Part D was May 15, and the Centers for Medicare & Medicaid Services (CMS) estimates that well more than 1 million beneficiaries signed up during the final week. CMS is still tabulating final enrollment numbers but has processed 872,000 enrollments from the final week. Many more from what it described as the “last-minute enrollment surge” are backlogged. This includes more than 500,000 persons who signed up online since May 7 – 143,875 of them on May 15. CMS estimates that more than 90% of Medicare beneficiaries—totaling more than 38 million people—now have some sort of prescription drug coverage.

Beneficiaries may have been motivated by the 1% per month penalty to be assessed permanently on the premiums of those who put off signing up until subsequent open enrollment periods. The next such window opens on November 15 and lasts for 6 weeks.

A bipartisan group of senators is sponsoring legislation to waive that penalty for the upcoming enrollment period. CMS already has waived the penalty for eligible beneficiaries choosing the low-income plan during the year 2006. The bill also would appropriate an additional $18 million for counseling to state-based programs such as the Area Agencies on Aging and Senior Health Insurance Information Programs.

Two Patient Assistance Programs for Part D Enrollees Pass Muster with OIG

This is good news for your patients who are Medicare Part D beneficiaries receiving Schering’s cancer medications through the pharma’s patient assistance program (PAP) called Schering-Plough: Commitment to Care. This PAP was one of the 2 Schering programs evaluated by the Office of the Inspector General (OIG). The other, called SP-Cares, includes most of Schering’s other medications.

In light of this news, GlaxoSmithKline announced plans to request the OIG’s opinion about its proposed PAPs for Part D enrollees. It also reversed plans to bar Part D eligible patients from its PAP programs after May 15, the deadline to sign up for Part D. These actions affect the firms’ PAPs for oncology and non-oncology medications.

The OIG opinion is noteworthy on a broader level because it clarifies how PAPs that include Part D enrollees can avoid conflict with the federal anti-kickback laws. The Office of the Inspector General (OIG) issued a bulletin last fall describing how PAPs might violate the federal anti-kickback statute. The bulletin was not intended to kill PAPs; in fact, it set out guidelines for how to reduce risk of breaching anti-kickback law while running a PAP that includes Part D enrollees. But some pharmas reacted by deciding to close or restrict access to their PAPs after May 15, the deadline to sign up for Medicare Part D.  This is what GlaxoSmithKline had planned to do until the OIG released its favorable opnion about the Schering PAPs.

The Senate Finance Committee wrote to the OIG on April 17, urging it to expedite responding to pharmas’ questions about whether individual PAPs comply with the law. The next day, OIG issued a favorable advisory opinion about the 2 Schering-Plough PAPs.

Standardized Part D Exceptions Request Form Available

This form, available on the Centers for Medicare & Medicaid Services (CMS) website,  allows enrollees to seek drug exceptions or prior authorizations. It is 1 page long and includes a provision to request expedited (ie, 24-hour) review of requests. Standard review time is 72 hours, according to the form. The American Medical Association (AMA) and America’s Health Insurance Plans (AHIP) collaborated to produce the document. The previous process to request exceptions required multiple, lengthy forms, according to the AMA. The form cannot be used to request biotech or other specialty drugs for which drug-specific forms are required.

CMS Issues 2007 Final Guidelines for Part D Formularies

Some key elements include requiring plans to include at least 2 drugs in each approved therapeutic category and class. The Centers for Medicare & Medicaid Services (CMS) may require more than 2 drugs if additional agents “present unique and important therapeutic advantages” and if excluding “may substantially discourage enrollment…by beneficiaries with certain disease states.”

The guidelines allow Part D plans to place “very high cost and unique items” in a specialty tier outside of the usual tiered cost-sharing. CMS indicates that specialty tiers must meet the following criteria for approval:

• Only 1 tier is exempted from cost sharing exceptions
• Only Part D drugs with plan negotiated prices exceeding $500/month can be placed in the specialty tier
• Cost sharing in the specialty tier is limited to 25% in the initial coverage range (or the actuarial equivalent for plans with decreased or no deductible basic alternative benefit design)

A recent evaluation of Medicare drug plans by the Kaiser Family Foundation found that most plans use these specialty tiers and some charge patients more than the 25% recommended by CMS. Eight of the 35 plans evaluated charged beneficiaries 30% to 33% of the cost of agents in the specialty tier. For at least one agent (etanercept for rheumatoid arthritis), a plan covered the drug but charged enrollees 75% of the cost – for a patient share of $1276.

Medicare Drug Plan Marketing Abuse

The Centers for Medicare & Medicaid Services (CMS) has another difficulty to overcome in helping seniors navigate the already confusing sign-up process for the new Medicare prescription drug plan—the hard-sell tactics of some private Medicare plan providers. Although Congress provided ample funding for private insurance companies to offer Medicare prescription plans, money was not set aside for state agencies to monitor the additional volume of policy sales. Jorge Gomez, head of the senior issues task force for the National Association of Insurance Commissioners, said the most blatant abuse has been “cross-selling, where salesmen were selling long-term care, annuities, and life insurance products” to customers seeking only to purchase a drug plan. There have even been reports of independent sales agents passing themselves off as employees of the Social Security Administration asking for personal data such as checking account numbers. Mr. Gomez, also Wisconsin’s Insurance Commissioner, warns, “Unless cross-selling is prohibited by Medicare, there will be a spike in fraud, stolen identities, and unsuitable sales.” Medicare has a 24-hour hotline (1-800-633-4227) to help explain the process for enrolling in Medicare prescription drug plans. Marketing complaints should be directed to a state insurance regulator.

New Drug Plan May Hurt Some with Special Needs

When the Medicare Prescription Drug Plan begins January 1, 2006, seniors and the disabled will finally have access to long-needed Medicare drug coverage. The plan is expected to save beneficiaries thousands of dollars a year and offers reduced premiums and deductibles based on need. However, health advocates warn that some beneficiaries could end up paying more under the new Medicare plan. Patients who are enrolled in both Medicaid and Medicare, particularly those in assisted-living, the mentally ill, or with a chronic illness, may lose benefits that cover a portion of their drug costs, and be unable to find a prescription plan that covers their specific medications. Jack Cheevers, a Medicare spokesperson in California, says they will continue to take suggestions from health advocates to further develop a system to ensure dual eligible Medicaid/Medicare beneficiaries can transition into a drug plan without any problems.

More Time to Enroll in Medicare Part D Drug Plan?

In response to confusion surrounding enrollment in the Medicare Part D Senior drug plan, Congressmen Pete Stark (D-Calif) and Jan Sharkowsky (D-Ill) have introduced legislation that would extend the application deadline from May 15, 2006, to December 31, 2006. Stark indicated that giving seniors an extra 6 months to choose plans would “provide beneficiaries extra protection during the first year of this complex new program so they won’t feel pressured into making a bad choice.” In addition, the bill would allow seniors to change plans within the first year and would prevent companies from canceling retiree health benefits for 1 year.

Medicare Part D Prescription Drug Plan’s E-Prescribing Program

Medicare beneficiaries are not the only ones confronted with important choices in the face of the January 1, 2006, start date of Medicare’s new prescription drug plan. Oncology practices will also face a decision as to whether their physicians will make use of Medicare Part D Prescription Drug Plan’s e-prescribing program. Participation by physicians and pharmacies is optional; however, if they choose to participate, they must comply with the Electronic Prescribing Standards, which were published by Centers for Medicare & Medicaid Services on November 7, 2005. “These standards will allow Medicare, physicians, hospitals, group practices, other health providers, and prescription drug plan sponsors and Medicare Advantage organizations to take advantage of e-prescribing technology, to improve medication prescribing for Medicare beneficiaries that participate in the new prescription drug program,” said Mike Leavitt, Secretary of Health and Human Services. All Medicare Part D Prescription Drug plan providers are required to support electronic prescribing, in an effort to encourage all physicians to eventually utilize this new and evolving technology.

Get Ready for Medicare Part D

Get ready for the whirlwind of confusion that will accompany the November 15, 2005 sign-up for the Medicare Part D Prescription Drug Plan (PDP). Medicare recipients, 65 years of age and older, will be attempting to decipher how to choose the PDP that best suits their needs. The Center for Medicare & Medicaid Services (CMS) has blanketed the market with a slew of services, including an online PDP plan chooser, a website to educate beneficiaries regarding Medicare Internet search techniques, and numerous television ads. Nonetheless, confusion already surrounds the complicated choices seniors face. In an ominously titled web article, Confusion Is Top Response at Sessions on RX Plan, William Q. Beard, a 73-year-old retired chemist from Wichita, Kansas, who takes eight prescription drugs including several heart medicines, commented, “I have a PhD and it’s too complicated to suit me. . . . I wonder how the vast majority of beneficiaries will handle this.” Similar sentiments have been echoed in national newspapers and television broadcasts this week. Mike Leavitt, Secretary of Health and Human Services, said that in addition to the CMS plan chooser, beneficiaries can get help sorting through their options by calling, toll-free: 1-800-633-4227. Patients can also be referred to local seminars. It’s time to consider what you can do to make this difficult and important choice easier for your patients.                                       
                                                   

CMS Provides Online Help for Choosing Medicare Part D Plans

The Centers for Medicare & Medicaid Services (CMS) has announced the launch of the Prescription Drug Plan Finder, an online resource to aid beneficiaries in choosing a Medicare Part D plan based on cost, coverage, and convenience. In addition, CMS is working with 140 community-based networks and nearly10,000 Medicare partners, including senior centers and State Health Insurance Assistance Programs, to aid in educating seniors about the ground-breaking and often controversial drug plan. “People do not need to make a decision now—they can’t sign up for a plan for another month and they can get coverage on January 1 as long as they enroll by December 31, 2005.  As we get closer to the time to enroll, the new tools will help people make those decisions,” said Mark B. McClellan, MD, PhD, CMS administrator.