Medicare Kidney Health Care Coverage by jolinmilioncherie

VIEWS: 1 PAGES: 36

									   Medicare: How It’s Changing
      To Help More People
          Medicare Part D Appeals and Grievances


                               Presented by:
                     Kidney Medicare Drugs
                Awareness and Education Initiative
                  www.kidneydrugcoverage.org

Kidney Medicare Drugs Awareness and Education Initiative   1
        KIDNEY MEDICARE DRUGS
       AWARENESS AND EDUCATION
               INITIATIVE

            A kidney community effort
            to help professionals and
      people with kidney disease understand
       Medicare prescription drug coverage


Kidney Medicare Drugs Awareness and Education Initiative   2
         Participating Organizations
 Abbott Laboratories                                National Minority Health Month Foundation
 American Association of Kidney Patients, Inc.                                     Association
                                                    National Renal Administrators Association
 American Kidney Fund                               Novartis Pharmaceuticals Corporation
 American Nephrology Nurses’ Association            Pfizer Inc.
 The American Society of Nephrology                 Pharmaceutical Research and Manufacturers of
 Amgen                                                  America
 Astellas Pharma US, Inc.                           PKD Foundation
 Centers for Medicare & Medicaid Services           Renal Care Group, Inc.
 Central Florida Kidney Center, Inc.                The Renal Network, Inc.
 DaVita, Inc.                                       Renal Physicians Association
 DaVita Patient Citizens                            Renal Support Network
 The ESRD Network of New York York                  Roche Pharmaceuticals
 Fresenius Medical Care North America               Sigma-Tau Pharmaceuticals, Inc.
                                                    Sigma-Tau Pharmaceuticals, Inc.
 Gambro Healthcare US                               Social Security Administration
 Genzyme Corporation                                Transplant News
 Kidney Care Partners                               The Transplant Pharmacy Coalition
 Nabi Biopharmaceuticals                            UnitedHealth Group/Ovations
 National Kidney Foundation, Inc.                   Washington Hospital Center
 • Council of Nephrology Nurses and Technicians
                                     Technicians    Wyeth Pharmaceuticals
 • Council of Nephrology Social Workers
 • Council on Renal Nutrition
 • People Like Us

Kidney Medicare Drugs Awareness and Education Initiative                                           3
   Prior Teleconferences in Series
 • August 16 teleconference – upcoming changes
   and extra help for those with limited income and
   resources
 • September 20–coverage coordination
 • October 18–choosing a Medicare drug plan
 • November 15—formularies, exceptions, and
   coverage determinations
 • December 20—filing appeals and grievances
 • For past teleconferences, see teleconference
   archive on www.kidneydrugcoverage.org
Kidney Medicare Drugs Awareness and Education Initiative   4
          Medicare Part D Overview
 • November 15, 2005: First date to join a
   Medicare drug plan
 • Dual eligibles can stick with the plan Medicare
   picked or choose another plan by December 31,
   2005 for it to start January 1, 2006
 • May 15, 2006: Last date for people with
   Medicare now to join without risk of penalties or
   waiting for open enrollment period
 • Anyone can start saving from Day 1 if they join a
   plan by December 31, 2005

Kidney Medicare Drugs Awareness and Education Initiative   5
                              Our Experts…
Moderator:
• Duane Dunn, lead social worker at DaVita
  Inc.
Speakers
• Vicki Gottlich, senior policy attorney at the
  Center for Medicare Advocacy, Inc.
• John Scott, Center for Beneficiary
  Choices, Centers for Medicare and
  Medicaid Services
Kidney Medicare Drugs Awareness and Education Initiative   6
        Review of Coverage & Cost
 • Formularies are lists of covered drugs
 • Tiers set co-pays or coinsurance amounts
 • Coverage limits
       – Prior authorization
       – Quantity limits
       – Step therapy




Kidney Medicare Drugs Awareness and Education Initiative   7
                    Review of Exceptions
 • A plan member may request a formulary
   exception:
       – To get a drug that’s not on formulary
       – To get a drug at a lower tier if no lower cost
         alternatives exist
 • MD certifies drug is medically necessary
   and other formulary drugs will be
   ineffective and/or cause adverse side-
   effects
Kidney Medicare Drugs Awareness and Education Initiative   8
            Plan Notification Timeline
 • Deadlines under which plans must
   respond after receiving MD’s supporting
   statement
       – 72 hours for standard request
       – 24 hours for expedited request (if patient’s
         life, health, or ability to regain function may be
         jeopardized)
       – If plan doesn’t act by deadline, plan must
         automatically forward request to independent
         review entity (IRE) for review

Kidney Medicare Drugs Awareness and Education Initiative   9
                  The Appeals Process
 • Medicare beneficiary can appeal a Medicare
   denial of services or payment
 • Part D appeals process is similar to Medicare
   Advantage appeals
 • Medicare beneficiary can appeal plan decision
   to deny drug coverage or payment
            •   For drug not on formulary
            •   If drug not considered medically necessary
            •   If drug furnished by out-of-network pharmacy
            •   If exception denied or dissatisfied with co-pay,
                coinsurance decision
 • If plan doesn’t meet deadline, IRE must review
Kidney Medicare Drugs Awareness and Education Initiative           10
        How Does Plan Member Learn
          About Appeals Process?
 • PDPs and MA-PDs must describe appeals
   process in writing in membership materials
   it sends to members
 • Plans must provide information on appeal
   rights on request
 • Plans must provide appeals information
   when plan issues an adverse coverage
   determination or redetermination

Kidney Medicare Drugs Awareness and Education Initiative   11
  Is Appeal Process the Same for All
        Medicare Drug Plans?
 • The process for accepting and processing
   appeals is the same for all plans.
 • All plans do not have to have the same process
   for evaluating the medical necessity of a
   requested drug.
 • Every plan must provide information to new
   enrollees when they enroll.
 • At pharmacy, if a drug is not covered,
   pharmacist refers patient to plan for more
   information.

Kidney Medicare Drugs Awareness and Education Initiative   12
  What Decisions Can Be Appealed?
 • Only adverse coverage determinations
       – Drug excluded from Part D
       – Drug not on plan formulary
       – Drug not considered medically necessary
       – Drug furnished by out-of-network pharmacy
       – Denial of formulary or tiering exception request
       – Failure to provide timely determination if it could
         adversely affect plan member
       – Cost sharing amount
 • Adverse redeterminations
Kidney Medicare Drugs Awareness and Education Initiative       13
                Plan Provides Notice of
                Coverage Determination
 • Plan must provide notice of adverse
   coverage determinations in writing
 • To meet deadline, plan may provide oral
   notice if followed with written notice within
   3 calendar days of oral notice




Kidney Medicare Drugs Awareness and Education Initiative   14
   More on Coverage Determinations
 • Pharmacy’s refusal to fill a prescription is
   not an “adverse coverage determination.”
 • Plan enrollees must make formal request
   for coverage determination with plan.
 • Network pharmacies must provide
   enrollees with CMS’ standardized notice
   about their right to request a coverage
   determination or exception.

Kidney Medicare Drugs Awareness and Education Initiative   15
               Step #1: Redetermination
 • Filed within 60 days of denial
 • Standard requests may be filed by enrollee or appointed
   representative
 • Standard requests must be filed in writing unless plan accepts
   phone
 • Plan must notify member in writing 7 days after receipt
   (standard appeal)
 • Expedited requests may be filed orally or in writing
 • Member, appointed representative, or MD can request
   expedited appeal if life, health, function could be jeopardized
   by waiting 7 days
 • Enrollee’s MD files supporting evidence orally or in writing
 • If plan grants request to expedite, plan has 72 hours to notify
   member of decision

Kidney Medicare Drugs Awareness and Education Initiative        16
               Step #2: Reconsideration
  If redetermination is denied:
  • Enrollee or appointed representative may file request for
    reconsideration by independent review entity (IRE)
  • Request must be filed in writing within 60 days after
    redetermination is denied
  • Can be filed as standard or expedited request
  • MD with experience in field where drug used reviews any
    denials based on lack of medical necessity
  • IRE must solicit prescribing MDs opinion and include in file
  • Plan must notify member in 7 days (standard request)
  • Member or appointed representative can request expedited
    appeal if life health or functioning may be seriously
    jeopardized
  • If IRE grants request to expedite or enrollee’s MD supports
    expedited appeal, plan has 72 hours to notify member in
    writing of decision
Kidney Medicare Drugs Awareness and Education Initiative           17
                Step #3: Hearing with
               Administrative Law Judge
 If reconsideration is denied:
 • Enrollee can request hearing with an ALJ.
 • Enrollee or appointed representative must
    file request in writing within 60 days of
    denial by IRE.
 • IRE decision tells where and how to file.
 • Minimum dollar amount is $110 in 2006.
    Amount may change each year.
Kidney Medicare Drugs Awareness and Education Initiative   18
  Step #4: Medicare Appeals Council
 If ALJ rules for plan:
 • Enrollee or appointed representative can
    request Medicare Appeals Council (MAC) review
 • MAC is Department of Health and Human
    Services entity that reviews ALJs’ adverse
    decisions
 • Enrollee or appointed representative must file
    written request within 60 days of ALJ decision


Kidney Medicare Drugs Awareness and Education Initiative   19
                       Appeal Step #5:
                     Federal District Court
 If the MAC does not reverse ALJ’s decision
 • Enrollee or appointed representative may
    request a review by a federal district court
 • The request must be filed in writing within
    60 days of MAC denial
 • Estimated annualized cost of disputed
    drug must be ≥$1,090 in 2006. Amount
    may change each year.
Kidney Medicare Drugs Awareness and Education Initiative   20
        What is CMS’ Responsibility in
              Appeals Process?
 • Monitor for compliance with regulations
   and other guidance
 • CMS can take enforcement action if plan
   is not satisfying CMS requirements




Kidney Medicare Drugs Awareness and Education Initiative   21
                          Coverage Gaps
 • Could have temporary coverage gaps
   during appeals
 • Sponsors must provide coverage and/or
   temporary medications in some cases
 • Plans don’t need to cover drug for life of
   appeal
 • January 17 teleconference is on filling
   coverage gap
Kidney Medicare Drugs Awareness and Education Initiative   22
          Representation In Appeals
 • Medicare beneficiary’s appointed representative can act
   for him/her at all levels of appeal to:
       – Make requests
       – Present or elicit evidence
       – Receive notice of appeal
 • Non-provider representatives can charge a fee (may
   need ALJ approval)
 • To appoint a representative, use form CMS-1696
   (Appointment of Representative) at www.medicare.gov
   (see Medicare Appeals and Appeal Forms)
 • Enrollee’s MD may seek a standard or expedited
   coverage determination or expedited redetermination
   without being enrollee’s appointed representative

Kidney Medicare Drugs Awareness and Education Initiative   23
       What Is Grievance Process?
 • All organizations selling Medicare drug plans
   must have grievance process to resolve
   complaints other than coverage determinations
 • Enrollee may file a grievance if dissatisfied with
   drug plan operations, activities, or behavior:
       – At pharmacy or with pharmacy benefit management
       – By any plan representative




Kidney Medicare Drugs Awareness and Education Initiative   24
      The Medicare drug plan decides
       if a complaint is an appeal or a
          grievance and has different
           process to resolve each.



Kidney Medicare Drugs Awareness and Education Initiative   25
                Examples of Grievances
 A grievance may involve a complaint about:
 • Problems getting through on phone
 • Quality of care
 • Quality of benefits
 • Interpersonal aspects of care
 • A plan’s benefit package
 • A plan not providing timely decisions (not a substitute for
   IRE forwarding)
 • Denial of request for expedited coverage determination,
   redetermination
 • The appeals process
 • Written notices and communications

Kidney Medicare Drugs Awareness and Education Initiative     26
           How Does a Plan Resolve a
                 Grievance?
 • Plans use dispute resolution techniques
   designed to consider complaints in a
   structured manner
 • Grievances do not go through a formal
   administrative appeals process




Kidney Medicare Drugs Awareness and Education Initiative   27
            Follow Up on Grievances
 • Plans must report grievances to CMS quarterly
 • Plan must have procedure to hear and respond to
   grievances in timely manner
 • Members have 60 days after event to file grievance by
   phone or in writing
 • Drug plan has up to 30 days to respond to grievance,
   depending on plan enrollee’s health status
 • Plan can extend deadline 14 days if it needs additional
   documentation to decide
 • If grievance is due to refusal to expedite and enrollee
   has not bought or received drug in dispute, plan must
   respond in 24 hours

Kidney Medicare Drugs Awareness and Education Initiative     28
     Question: Door-to-Door Sales
 • Plans are prohibited from selling Medicare
   Part D plans door-to-door
 • Call 1-800-MEDICARE and file complaint




Kidney Medicare Drugs Awareness and Education Initiative   29
  Question: Legal Representation
 • An attorney is not needed to file an appeal
 • Those who can’t afford legal counsel may
   be eligible for free legal help through
   state’s legal services program or state
   department on aging
 • Call county bar association for more
   information


Kidney Medicare Drugs Awareness and Education Initiative   30
            Question: Appeals to IRE
 • CMS contracted with MAXIMUS
 • MAXIMUS has experience:
       – Reviewed subsidy eligibility appeals for
         Medicare drug card program
       – Served as IRE for Medicare Advantage
         program
 • MAXIMUS can increase staff to respond to
   increasing workloads

Kidney Medicare Drugs Awareness and Education Initiative   31
                Take Away Messages
 • PDPs and MA-PDs must notify enrollees of appeal,
   grievance rights in writing
 • There are deadlines for appeals and grievances
 • The plan decides if a complaint is an appeal or grievance
 • Appeals process includes a plan review, an independent
   external review, and review by an ALJ, the MAC, and a
   federal court, if necessary
 • Plans handle grievances using structured approach
 • CMS gets quarterly notice of complaints
 • There could be a gap in coverage for a disputed drug
   during the appeals process

Kidney Medicare Drugs Awareness and Education Initiative   32
                                 Thank You
Moderator:
• Duane Dunn, lead social worker at DaVita
  Inc.
Speakers
• Vicki Gottlich, senior policy attorney at the
  Center for Medicare Advocacy, Inc.
• John Scott, Center for Beneficiary
  Choices, Centers for Medicare & Medicaid
  Services
Kidney Medicare Drugs Awareness and Education Initiative   33
                           Key Messages
 • Medicare drug plan will help some; others may
   not need it
 • Most information you read is for the “average”
   person with Medicare
 • Kidney Medicare Drugs Awareness and
   Education Initiative provides kidney-specific
   information
 • Choose a plan to cover most drugs for most help
 • Ask patients to bring notices to review, advise
   about creditable coverage, keep for appeals

Kidney Medicare Drugs Awareness and Education Initiative   34
                   The right information
                    at the right time…



Kidney Medicare Drugs Awareness and Education Initiative   35
    Thank You For Participating…
 • Listen at noon ET on January 17, 2006 for information
   on filling the coverage gap
 • Visit www.kidneydrugcoverage.org for today’s materials
 • Register for teleconference notice and site updates:
       – 4 booklets for patients (NEW)
       – Compare Drug Plans packet (NEW)
       – 40 individualized fact sheets (Coming Soon)
 • Complete evaluation
 • Print your certificate of attendance
 • Ask your licensing board if certificate can be used for
   continuing education credit
 • Submit questions about Medicare Part D to
   info@kidneydrugcoverage.org


Kidney Medicare Drugs Awareness and Education Initiative     36

								
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