RSS

On May 23, 2019, Ways & Means Committee Chairman Richard E. Neal (D-MA) and Energy & Commerce Committee Chairman Frank Pallone, Jr. (D-NJ), along with Ranking Members Kevin Brady (R-TX) and Greg Walden (R-OR) announced a solicitation for comments on draft legislation to reform the Medicare Part D program that would establish an out-of-pocket cap … Read more

June 6, 2019 Via Electronic Submission to PartDImprovements@mail.house.gov The Honorable Richard Neal                             The Honorable Frank Pallone Chairman                                                    … Read more

On January 30, 2019, the Centers for Medicare & Medicaid Services (CMS) issued Part II of its draft 2020 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that want to participate in Medicare in the following calendar year. In collaboration with several … Read more

While the President’s State of the Union Address was short on substance concerning health care, he did mention a desire to work with Congress to “lower the cost of health care and prescription drugs.” While the President focused on “global freeloading” there is one common sense solution that would make drugs more affordable for individuals, … Read more

The Center for Medicare Advocacy recently submitted comments to a Notice of Proposed Rulemaking issued by the Centers for Medicare & Medicaid Services (CMS) entitled “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses” (CMS-4180-P).  The Center’s comments are available at: https://www.medicareadvocacy.org/center-comments-on-modernizing-part-d-and-medicare-advantage/.   Currently, Part D prescription drug plans (PDPs) … Read more

On January 29, 2019, the Senate and House held separate hearings on prescription drug prices. The Senate Finance Committee’s hearing, Drug Pricing in America: A Prescription for Change, Part 1, explored the rising cost of prescription drugs and potential solutions to the ongoing crisis. In his opening testimony, Ranking Member Ron Wyden stated that “[m]ore … Read more

With the mid-term elections just days away, the President unveiled a minimal drug proposal in yet another effort to suggest minor changes at a politically opportune time. This is a distraction from the fact that the Administration is not “strengthening” Medicare as claimed, but fragmenting it and putting it on a path to privatization. Don’t fall for the … Read more

September 2018 Numerous changes were made to Medicare law, regulations and guidance during the first half of 2018.The changes are particularly noteworthy regarding Part C, governing private Medicare plans, known as Medicare Advantage (MA), and Part D, the prescription drug benefit.This report focuses on the impact to Medicare beneficiaries from changes to Parts C and … Read more

The Office of the Inspector General for the Department of Health and Human Services released a report recently regarding Part D coverage of prescription drugs used by people dually eligible for Medicare and Medicaid. The June report, Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2018, found that most Part D plan … Read more

Robert Pear wrote last week in the New York Times (“Trump Plan to Lower Drug Prices Could Increase Costs for Some Patients”) that the President’s plan to “inject more competition into the market” and switch coverage of some expensive drugs from Medicare Part B Medicare Part D could significantly increase out-of-pocket costs for some of … Read more

On April 6, 2018 the Center for Medicare Advocacy and Florida Health Justice Project filed a lawsuit in U.S. District Court for the Southern District of Florida on behalf of a 49-year-old beneficiary seeking Medicare coverage for his “off-label” (non-FDA-approved) use of a critically needed medication (Dobson v. Azar, 4:18-cv-10038-JLK).  The beneficiary’s Medicare Part D … Read more

Center for Medicare Advocacy and Florida Health Justice Project Sue to Obtain “Off-label” Part D Prescription Drug Coverage for Beneficiary

April 16, 2018 For Immediate Release Contact: Center for Medicare Advocacy – Kata Kertesz: KKertesz@MedicareAdvocacy.org, 202-293-5760 Florida Health Justice Project – Miriam Harmatz: Harmatz@FloridaHealthJustice.org, 786-853-9385 On April 6, 2018 the Center for Medicare Advocacy and Florida Health Justice Project filed a lawsuit in the United States District Court for the Southern District of Florida on behalf of … Read more

On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2019 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that wish to participate in Medicare in the following calendar year.  In collaboration with several other advocacy organizations, … Read more

Representative Sandy Levin recently introduced the Protecting Medicare from Excessive Price Increases Act, which would require prescription drug manufacturers to pay a rebate when the price of their Part B drug increases faster than inflation. Medicare Part B covers drugs that are usually not self-administered, such as many intravenous medications and chemotherapy drugs. Medicare Part … Read more

As noted in a previous Alert, the Center for Medicare & Medicaid Services (CMS) recently finalized their 2018 Call Letter.  In the same document, CMS issued a Request for Information regarding ideas for “regulatory, sub-regulatory, policy, practice and procedural changes to better accomplish” the goals of “using transparency, flexibility, program simplification and innovation to transform … Read more

April 24, 2017 VIA ELECTRONIC SUBMISSION PartCDcomments@cms.hhs.gov Seema Verma, Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Baltimore, MD 21244 Re:                  2017 Transformation Ideas – Response to Request for Information re: Medicare Advantage and Part D Dear Administrator Verma: The Center for Medicare Advocacy (Center) is pleased to provide … Read more

Note:  The amounts in this table do not apply to beneficiaries who have the Part D Low Income Subsidy (“Extra Help”) Annual Deductible Maximum $400 Initial Coverage Period Cost sharing during this period may be a flat 25% co-insurance OR the plan may have a tiered system of co-pays and co-insurance that is actuarially equivalent … Read more

Prescription Drug Pricing An excellent and well-timed (given #Epi-gate) article appeared in this week’s Journal of the American Medical Association discussing the reason drug costs are so high in the U.S. According to the article, the major cause is the “granting of government-protected monopolies to drug manufacturers, combined with restriction of price negotiation at a … Read more

In the last 18 months, the Center for Medicare Advocacy, and other advocates around the country, have received many, many calls from older and disabled beneficiaries who can no longer obtain coverage for the Lidocaine Patch 5% from their Part D plans. Many have been using the Patch for at least a decade and are … Read more

The Medicare Advocacy Project of Greater Boston Legal Services recently received a favorable decision from the U.S. District Court in Massachusetts for “off-label” coverage of the drug Dronabinol.  This is a welcome development given how difficult it has been to obtain coverage for medications that prescribing doctors agree are necessary, but that are not FDA-approved … Read more

March 2016 Update: CMS is now delaying enforcement of the Part D Prescriber Enrollment Requirements until February 1, 2017. Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by January 1, 2016, or earlier, to ensure that MACs have sufficient time … Read more

Low income racial and ethnic minority beneficiaries are adversely affected by prescription drug pricing, a problem that has a negative impact on overall Medicare program costs.  A 2011 International Journal of Health Services study estimates that the economic costs of health disparities due to race for African Americans, Asian Americans, and Latinos from 2003 thru … Read more

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) released a statement on October 30, 2015 that advises hospitals that it will not administratively sanction them if they discount or waive charges for an outpatient’s self-administered drugs. Thus, hospitals now have the option, and a greater incentive, not … Read more

This page focuses on programs that help Medicare beneficiaries acquire necessary medications, although many of the programs discussed are not limited to that population.  Many Americans who are still feeling the effects of the recession are struggling to find ways to save money and pay for their medications. Unfortunately, some have been forced to make … Read more

On November 20, 2015, Center staff attended a one day symposium hosted by the federal Department of Health and Human Services (HHS) entitled “HHS Pharmaceutical Forum: Innovation, Access, Affordability & Better Health.”  The forum featured HHS Secretary Burwell, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS), Andy Slavitt, consumer advocates, pharmaceutical company … Read more

In a report entitled “Medicare Part D: A First Look at Plan Offerings in 2016” (October 2015), the Kaiser Family Foundation analyzed the Part D market in 2016 and found, among other things, that: In 2016, beneficiaries in each region will have a choice of 26 PDPs, on average, down by 4 from 2015. The … Read more

Every year, the Centers for Medicare and Medicaid Services (CMS) issues payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject … Read more

Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in … Read more

On February 12, 2015, the Centers for Medicare and Medicaid Services (CMS) published final rules entitled “Medicare Program; Contract Year 2016 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs” [CMS-4159-F2], otherwise known as the final 2016 rules for Medicare Parts C and D.[1] Applicable to the 2016 plan … Read more

A Brief Survey of Recent Reports, and a New Special Enrollment Period for 2015 Medicare's Annual Coordinated Election Period (ACEP) for Medicare Advantage and Part D plans began on October 15th and runs through December 7th.  During the ACEP, often referred to as "open enrollment," Medicare beneficiaries who do not have a Part D plan … Read more

Hospital Deductible: $1,260.00 / Benefit period Hospital Coinsurance: Days 0-60: $0 Days 61-90: $315 / Day Days 91-150: $630/ Day Skilled Nursing Facility Coinsurance: Days 1-20: $0 Days 21-100: $157.50/ Day Part A Premium (For voluntary enrollees only) With 30-39 quarters of Social Security coverage: $224.00 / Month With 29 or fewer quarters of Social … Read more

Quick Summary When Medicare beneficiaries elect the hospice benefit, they waive Medicare coverage for all care and services related to the terminal illness that are not on the hospice plan of care and provided through the hospice provider.  This means that when a terminally ill beneficiary elects hospice, all of the medications needed to control … Read more

Research suggests that medications that should be covered by the Medicare Hospice Benefit are sometimes paid for by Medicare Part D plans. In March, to prevent this from happening, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for … Read more

The use of Medicare observation status in hospitals has increased dramatically over the past several years.[1] The most notable adverse consequence of Observation Status on beneficiaries is financial liability for any post-hospitalization care at a Skilled Nursing Facility.[2] However, many of the beneficiaries the Center assists also find themselves facing large hospital bills for drugs … Read more

On March 10, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance" (Guidance).   The Guidance identifies a billing problem related to medications after Medicare beneficiaries elect hospice, and … Read more

Programs that help low-income people afford their Medicare, including the Medicare Savings Programs and the Part D Low Income Subsidy (also called LIS or Extra Help) have income and resource eligibility guidelines that change yearly. The Federal poverty level (FPL) guidelines for 2014 were published in the Federal Register on January 22, 2014.[1]  These guidelines … Read more

The Medicare Part D Prescription drug program is forbidden by law from getting the best prices for prescription drugs. Unlike the Veterans Administration and Medicaid, Medicare is at the mercy of drug company pricing, forbidden from seeking lower prices for its enrollees. Allowing Medicare to get fair drug prices would save billions of taxpayer dollars a year, without … Read more

During the Annual Coordinated Election Period, which runs from October 15th through December 7th, people with Medicare can change their choice of health coverage (whether they receive that coverage through a private Medicare Advantage plan or traditional Medicare), and add, drop or change Medicare Part D drug coverage. For more information and to get help … Read more

In the midst of ongoing budget discussions, policymakers are considering a wide array of approaches for cutting spending and saving federal dollars. The Center for Medicare Advocacy recently wrote of ways to strengthen the Medicare program while achieving significant savings.[1] Included in our analysis was a proposal that would save taxpayers billions of dollars: reinstating … Read more

The Medicare Advantage Disenrollment Period (MADP) lasts from January 1st through February 14th of each year.  During the MADP, a beneficiary can switch from an MA plan to traditional Medicare. The new MADP also provides an opportunity to enroll in a Part D drug plan for those who have not already done so. When disenrolling … Read more

Although passage of the Affordable Care Act (ACA) has achieved considerable savings for the Medicare program, Medicare is still being targeted by policymakers looking to negotiate a large "grand bargain" deficit-reduction package. Many of the proposals to achieve Medicare savings would shift costs from the federal government to Medicare beneficiaries As the debt and deficit … Read more

As discussed in last week’s Alert, the current Medicare Annual Enrollment Period lasts until December 7th.[1]  During this time period, Medicare beneficiaries can choose a Medicare Advantage (Part C) or Part D plan for 2013.  This Alert discusses Part C and D plan quality ratings for 2013, and special enrollment periods related to these ratings.  … Read more

As a result of the Budget Control Act, which outlined mandatory cuts to both defense and non-defense discretionary programs in the event a Congressional committee could not agree to a deficit-reduction package, programs impacting the HIV community and funding are expected to be affected. According to the AIDS Institute, over $500 million would be cut … Read more

On July 19, 2012, the Secretary of Health & Human Services (HHS), Kathleen Sebelius, announced the availability of roughly $80 million dollars in grant money to increase access to HIV/AIDS care, including eliminating waiting lists,[1] which have been a challenge in operating the Aids Drug Assistance Program. A Global Pandemic HIV/AIDS remains a global pandemic … Read more

New data released this week shows that families and individuals who rely on Medicare continue to see direct benefits from the Affordable Care Act by saving billions of dollars on prescription drug costs.[1] So far in 2012, older and disabled Americans have saved an average of $837 on their drug purchases after reaching the donut-hole … Read more

Effective January 1, 2012, Medicare Part D plan enrollees who are unable to obtain a prescription drug at the pharmacy are now, in most instances, entitled to a written notice explaining how they can contact their Part D plan in order to initiate an appeal.  On February 2, 2012, CMS announced that the final model … Read more

On October 27, 2011 the Centers for Medicare and Medicaid Service (CMS) released notices detailing the Medicare Part A and Part B premiums and Deductibles for calendar year 2012. Hospital Deductible: $1,156 per spell of illness Hospital Coinsurance: Days 0-60: $0 Days 61-90: $289 / day Days 91-150: $578 / day Skilled Nursing Facility Coinsurance … Read more

Once again the Medicare Advantage and Part D Annual Coordinated Election Period (ACEP) is upon us; it's time to contemplate Medicare prescription drug and Medicare Advantage choices for another calendar year.  The big news is that the ACEP, while one week longer than in the past, starts and ends much earlier this year.  The ACEP … Read more

Fall is the time for Medicare beneficiaries to explore their options regarding Part D prescription drug and Part C Medicare Advantage plans.  In years past, the annual enrollment period began in mid-November and lasted to the end of the year, with any changes or choices made effective January 1st.  Starting this year, that time period … Read more

On April 15, 2011, the Centers for Medicare & Medicaid Services (CMS) issued final regulations to provide policy and technical changes to the Medicare Parts C (Medicare Advantage) and D programs.[1]  The regulations address concerns raised by Medicare beneficiary advocates, and implement provisions of the Affordable Care Act.  They also codify into regulation some existing … Read more