Friday, January 05, 2007


As anyone who visits this blog regularly probably knows, I work in a call centre representing one of the providers for the Medicare Part D prescription drug plan. I provide information to callers interested in signing up with the programme as well as enrolling new members and dealing with pharmacies and physicians' offices. We just completed the open enrollment period for 2007, the annual time when Medicare members can join a Part D provider if they were not enrolled with one during the previous year or can change their provider if they wish.

The federal Centers for Medicare and Medicaid Services (CMS), the agency which runs the programme, needs to seriously consider making some changes. First on the list would be to change the open enrollment period from the current November 15 - December 31 to October 13 - November 31. The reason for this is simple: CMS approves every application for Part D coverage, even those for individuals who wish to change their provider. Due to the crush of applications from across the country, that means an inevitable backlog. At one point, CMS reportedly had a three week backlog of applications to consider; even now it's between 7-10 days. That means that thousands of people who may need prescription drugs right away and believed their coverage would begin January 1 are having to pay out of pocket (at least, those who are able to do so) for those meds until CMS approves their application and receive notification from their provider that they are now enrolled.

Moving the open enrollment period would also help in insuring that an applicant's payment option will be ready to be handled when coverage begins January 1. A lot of people who applied during the last part of December and opted to have their monthly premimums deducted from their Social Security benefit checks will likely be "doubled up" in February, as it would have been too late to communicate their option to SSA in time for January's payment. Other payment options, such as automatic bank drafts, also take time for notification.

A lot of folks, myself included, were fustrated with the crush of calls we received during the last few days of the open enrollment period and were wondering why people waited until the last minute (almost literally) to sign up when they have a month and a half to do so. One reality that I discovered is that one major provider was calling members right up until New Year's weekend to advise subscribers that they were changing key elements of one of it's most popular programmes. These folks had little, if any, time to shop around for another plan and ended up signing up with little idea of what their new plan was about except for what they were told at a pharmacy or from others. I made the time to review our client's plans in detail with callers in this situation to try to insure that they had some understanding of the coverage, benefits, and costs involved.

Needless to say, any provider that is changing their plan for the new year should be required to notify their plan's subscribers up to 60 days in advance.

And people really need to know that shopping around is a huge part of the Part D programme. In some states, there are 50 or more companies contracted as Part D providers, and each has it's own formulary...the list of drugs which that plan will provide. Needless to say, no plan will cover each and every medication on the market. While exceptions are available for drugs not covered, they require physicians provide evidence to justify the need for the non-formulary medication for approval...and approval is not guaranteed, but handled on a case-by-case basis based on what information is provided by the physician. In some cases, a patient may be required to try a similar medication which is covered for a specific length of time before their drug of choice will be considered.

One other item people should consider deals with relatives or spouses of people who are applying for Part D coverage. Regulations regarding releasing any information regarding a member's coverage and benefits as well as general enrollment are very strict due to the privacy aspects of the federal Health Insurance Portability and Accountability Act (HIPAA). Therefore, it's important for a member to designate in writing a person or persons who they authorize to discuss their enrollment issues with. And family members who are enrolling a person who is not able to do so themselves have to realize that they need to include either a written statement from their loved one giving them authorization or a Durable Power of Attorney for Healthcare Issues. Without those, we cannot discuss anything.

Now is the time to begin work for next year...


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