Medicare Part D - Kaiser Papers

CENTER FOR MEDICARE ADVOCACY WRITES ISSUE BRIEFS ON MEDICARE PART D
FOR KAISER FAMILY FOUNDATION

The Center for Medicare Advocacy was recently commissioned by the Kaiser Family Foundation to write two issue briefs on Medicare Part D: Oversight and Enforcement of Medicare Part D Plan Requirements: Federal Role and Responsibilities and An Exploration of Beneficiary Challenges in Using the Medicare Part D Appeals Process to Obtain Medically Necessary Drugs. The full text of each paper is available at www.kff.org by clicking on the title, below.

Oversight and Enforcement of Medicare Part D Plan Requirements: Federal Role and Responsibilities, by attorney Toby S. Edelman, looks into legal advocates’ views of how CMS and the U.S. Department of Health and Human Services Office of Inspector General (OIG) enforce compliance with requirements of the new Medicare Part D Prescription Drug benefit. It begins with a discussion of “potential schemes, risks, and vulnerabilities in the Part D benefit” and then considers the authority given to OIG and to CMS by law, regulation, and contract to enforce Part D requirements. It turns next to CMS’s “Part D Oversight Strategy” and interpretation of its authority, which methods CMS uses to determine plans’ compliance with Part D requirements, whether CMS can enforce its informal guidance, and finally, whether and how CMS has used its enforcement authority.

An Exploration of Beneficiary Challenges in Using the Medicare Part D Appeals Process to Obtain Medically Necessary Drugs, by attorney Vicki Gottlich, describes the various steps of the Medicare Part D appeals process for obtaining necessary drugs not on a plan’s formulary. It illustrates with case reports challenges and problems encountered by beneficiaries in navigating this aspect of the drug benefit. The paper concludes with a discussion of potential policy options including the implications of establishing an exceptions and appeals process that is uniform in paperwork and procedures.