MARCH 31, 2006 -- Ten Senate Democrats have asked President Bush to extend transitional drug coverage now set to expire April 1 for millions of Medicare beneficiaries, so seniors and the disabled have access to necessary drugs.
"We're very concerned that many elderly and disabled citizens will not be able to obtain the drugs they desperately need if the transition policy ends," the senators wrote. "There has still been little or no education as to what happens when the transition policy ends, including how to file appeals."
The transitional coverage for beneficiaries enrolled in the drug benefit, which began Jan. 1, had originally been designed to last just 30 days. On Feb. 1, the Department of Health and Human Services extended that period to April 1 because of confusion among some beneficiaries over which drugs were covered by specific health plans and concerns that beneficiaries needed to maintain their drug regimens as they and their physicians determined if they could switch to another drug listed on a plan's formulary.
Beneficiaries whose transitional assistance expires April 1 will have to file for an exception or appeal with their health plan to get coverage for a drug not listed on the plan's formulary. Some health care analysts say Medicare drug plans have done a poor job of informing beneficiaries who qualify for the special coverage that it will end April 1. They also say the lack of a standardized form to appeal a coverage decision makes it difficult to get coverage for drugs not covered by a particular plan.
Centers for Medicare and Medicaid Services (CMS) Administrator Mark B. McClellan said Friday that CMS has told plans they need to take steps to help beneficiaries successfully transition to a formulary drug or take action needed to help beneficiaries maintain their current medication. McClellan also said CMS is monitoring how plans act on requests for exceptions and appeals requests and will impose fines and other penalties if plans have acted inappropriately. "Well under half" of beneficiaries who used transitional coverage have not transitioned fully to drugs covered by their health plans, McClellan said.
In a March 30 memo to drug plan sponsors, CMS warned that "the end of the transition period could produce a significant increase in exceptions and appeals requests." Drug plan enrollees, CMS said, should not discover at the pharmacy counter that they have to obtain prior authorization for a drug not covered by their plan, nor should they face delays because appeals or exception requests have not been resolved.
In situations where plans are unable to meet specific time frames for an exception or appeal request, enrollees should be given a temporary supply of the drug in question until the case is fully resolved, CMS said.
As the 90-day transition period ends, the insurance industry is "reaching out to beneficiaries, their physicians and pharmacists to provide information about plan processes for exceptions and appeals and alternatives to non-formulary drugs," Karen Ignagni, president and chief executive officer of America's Health Insurance Plans, said in a statement.
McClellan said beneficiaries who enroll in the drug benefit after April 1 qualify for 30 days of transitional assistance. That period increases to 90 days for beneficiaries enrolled in institutional settings or who are moved from one facility to another, such as from a hospital to a nursing home.
McClellan also said a standardized form for coverage appeals and exceptions would be posted on the CMS Web site within days.