RAO Davao City

United States Military Retiree Activities Office Davao City, Philippines

MEDICARE Part D UPDATE September 14, 2008

Posted by Service Officer on September 14th, 2008

Medicare regulations establish an appeals process that, in theory, can be navigated by any person with Medicare who has been denied coverage for a prescription by his or her Part D plan. But problems frequently arise because Medicare Part D plans refuse to abide by the rules and prevent people from getting medically necessary medicines. These are the most common obstacles patients face:


1. Plans ignore appeals submitted by members and their physicians. Part D plans routinely fail to respond to requests for drug coverage. Time and again patients or their physicians submit requests for coverage and weeks, if not months, pass before their plan reached a decision—if one was provided at all.

2. Consumer representatives cannot provide information to members about the status of their appeals. When Part D enrollees do not receive a response to their appeal, it is virtually impossible to get any information about the status of a pending appeal from Plan customer service representatives. When advocates call customer service lines to inquire on behalf of clients, they are told that consumer representatives have no access to the appeals database. Advocates are then referred to another hotline, and forced to leave messages. Guess what? Often, these messages are never returned.

3. Plans do not take into account submitted medical support, but rather “rubber stamp” denials, and customer service representatives cannot advise members what (additional) medical documentation is needed. Part D plans notoriously fail to read physicians’ supporting statements indicating that alternative medications have been harmful or ineffective. Plans deny medications for failure to meet step therapy or prior authorization requirements even when physicians explicitly indicate that such requirements have been met. Furthermore, when frustrated members call their plan for advice, customer service representatives routinely tell them they must meet plan requirements. They rarely, if ever, provide substantive advice about the appeals process or what additional medical information may be necessary to win an appeal.

4. Customer service representatives often misinform members about their appeals rights. Medicare private plans must abide by strict timelines in issuing decisions. Plans must return decisions on standard (not expedited) exception requests for coverage within 72 clock hours and appeals decisions within seven calendar days. Clients who call their Part D plans to find out the status of their appeals are repeatedly been told by representatives that these timelines count only business hours, not clock hours. Plan representatives claim that the plans have 30 days to make decisions. This is only true for grievances, not for requests for coverage.

By making the appeals process as frustrating and protracted as possible, Part D plans are driving many of their enrollees to simply give up and either stop taking needed medications or pay out of their own pockets. The Medicare rights Center (MRC) has created an advocate’s manual for navigating the Medicare private drug plan appeals process . This easy-to-understand Part D appeals manual has consumer-friendly language for advocates who help people with Medicare get the drugs they need. This 25-page manual offers a complete overview of the entire appeals process, real-life case examples from their Client Services department, a glossary of important Part D appeals terms, a sample appeals protocol for advocates, and links to important resources and documents. The manual can be accessed and downloaded at http://www.medicarerights.org/partd_appeals_manual.pdf. [Source: Asclepios/MRC Advocacy 14 Aug 08 ++]

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