Bipartisan Part D Off-Label Prescription Parity Act Re-introduced in Congress
On Friday, March 11, U.S.
Thornberry (R-TX) and Russ
re-introduced the bipartisan Part D Off-Label Prescription Parity Act (H.R. 1055). The bill clarifies that Medicare should consider peer-reviewed medical literature when determining coverage for off-label drugs, as is the case under Part B and for Part D drugs used to treat cancer. Currently, the Centers for Medicare & Medicaid Services (CMS) allows coverage of off-label drugs under Part D for drugs used to treat conditions other than cancer only if such use is supported by a listing in statutorily identified, privately owned and published drug guides known as compendia. The Part D Off-Label Prescription Parity Act ensures uniformity in coverage standards for off-label medications across the Medicare program, regardless of condition. However, recognizing the importance of consumer safety, the legislation does not require Medicare to automatically cover drugs used for off-label purposes; it simply requires Medicare to consider such evidence in determining if a drug is medically necessary during the existing Part D coverage determination and appeals process.
The introduction of the legislation follows another breakthrough in Medicare’s off-label coverage standard. Last week, a federal court in the Southern District of New York found, in a case filed by the Medicare Rights Center, that CMS’s interpretation of the law is too restrictive, and that Medicare may look beyond compendia to determine if coverage of drugs used for off-label purposes is appropriate. Although the ruling is binding only in parts of New York, the legislation would apply the tenets of the ruling nationwide.
Read Medicare Right Center’s letter of support.
Read Medicare Rights Center President Joe Baker’s statement.
MedPAC Recommends Modest Payment Changes for Most Providers
This week, the Medicare Payment Advisory Commission (MedPAC) released its annual report, which contains recommendations for 2012 payment rates for Medicare providers. For physician services provided under Part B, which covers outpatient care, MedPAC recommended an increase in payment rates of 1 percent. Although some view this as a modest increase in payments, MedPAC found through surveys and research that most Medicare consumers did not report problems accessing physicians or scheduling timely appointments. In fact, most reported better access to physicians than privately insured individuals aged 50 to 64. The commission also recommended an increase of 1 percent in payments for hospitals, but recommended no payment increases for several provider groups, including those in long-term care hospitals and skilled nursing facilities.
Home health payment rates received great scrutiny by MedPAC due to high rates of fraud related to home health care. The commission recommended that Congress require the Secretary of Health and Human Services (HHS) to rebase payments in home health and eliminate the market basket update in 2012. Furthermore, MedPAC advised the Secretary of HHS to work with the Office of Inspector General to implement new authority to identify locations with high rates of fraud and suspend provider enrollment and payment in those areas. Lastly, MedPAC recommends that Congress establish cost-sharing for home health services when not preceded by a stay in an acute care facility such as a skilled nursing facility or hospital. This recommendation is controversial among consumer advocates because it would create a new cost burden for Medicare consumers, who currently pay nothing out of pocket for home health care. According to a recent study by the Kaiser Family Foundation, nearly half of all Medicare consumers have household incomes of $20,000 or less (under $1,700 per month).
Lastly, MedPAC found that in 2011, Medicare spent 10 percent more per patient enrolled in Medicare private health plans, also known as Medicare Advantage (MA) plans, than it would have if those same patients were enrolled in Original Medicare. These overpayments are paid for through increased premiums for all Medicare consumers (about $36 per person per year in 2009). The Affordable Care Act (ACA) phases out the overpayments and replaces them with bonus payments based on quality ratings. Although there was no increase in payments to MA plans this year, MedPAC found that consumers still had a copious number of plan options.
Read the fact sheet on MedPAC’s report to Congress.
Read MedPAC’s full report.
If your Medicare prescription drug plan decides not to cover a drug you have requested, you have the right to appeal.
- Your plan should send you a written denial titled "Notice of Denial of Medicare Prescription Drug Coverage." The notice should clearly explain why the plan is denying coverage for your prescription and tell you where to send your appeal.
- You have 60 days from the date on the "Notice of Denial" to submit your appeal. (Under certain circumstances, you may be able to appeal after 60 days if you have "good cause"—for example, if you were in the hospital and therefore could not appeal earlier.) By appealing, you are asking for a "redetermination" from the plan.
- The plan must respond no later than seven calendar days from the date it received the request. If it is an emergency, you or your doctor can ask for an "expedited" redetermination. Your plan must respond to an expedited appeal within 72 clock hours.
- If you have to pay for your drug out of pocket since your plan denied your exception request, be sure to submit receipts and request reimbursement from your plan in your appeal.
- If your plan denies you again, get an independent review.
Learn more about the appeals process at www.MedicareInteractive.org.
Medicare Rights is marking the first anniversary of the Affordable Care Act (ACA) with a free webinar, Health Reform and Medicare. Set for Tuesday, March 22 from 2:00 to 2:30 p.m., Eastern Time, the webinar has already reached capacity due to popular demand. Fortunately, a link to the recording will be available on www.medicarerights.org shortly after the event ends.
Whether or not you are able to participate in the webinar or view the recording, please keep sending us your questions about health reform and Medicare. Look for more answers in upcoming issues of Medicare Watch in our feature Health Reform Q and A.
Click here to send us your questions.