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Two Medicare Policies Should be Changed

1. Every Physician should display a list of Medicare Advantage plans to which they are an in- network provider.

 

As it is, only insurance companies have to provide a list of physicians and health organizations that are in-network. The problem with the current policy is that many, if not most, in-network physicians

are not listed by name but only by their employer who signs the contract with the insurance company.  In some cases, it is difficult for the patient to know the name of their doctor's employer.  For example, my primary care physician (PCP) was employed by MacNeal Hospital, which was purchased by Loyola Medicine, which is owned by Trinity Health, which employs 5300 physicians.  Oh, gee, what could go wrong?   I accidentally selected a Cigna Medicare Advantage Plan to which my PCP is out of network.  I submit that the current policy is error fraught.

 

2. Prior authorization of drugs should be between the patient and Medicare instead of between the patient and the insurance company.

 

As it is, a patient and physician have to fill out large amounts of paperwork, to get the same drug approved, every time the patient changes insurance companies, and, each time, approval is uncertain.  That policy stifles competition between insurance companies by providing an unfair incentive for a patient to keep the insurance company that approved the drug.

 

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@aruzinsky wrote:

1. Every Physician should display a list of Medicare Advantage plans to which they are an in- network provider.

 

 

2. Prior authorization of drugs should be between the patient and Medicare instead of between the patient and the insurance company.

 

 

 


1,  Yes, this is confusing and has gotten a lot worse since many hospitals have now bought out physician practices.  Best thing to do is call and talk to the insurance processor in your physicians office - the individual physician probably doesn't know.  

 

This would be a good suggestion to get to Medicare (CMS) and send a copy of your letter to your US House Rep. 

 

When they were just combined in a group of physicians, each one could have different coverage options within the group.  I don't know if that is the case if the WHOLE group is now owned by some medical conglomerate.

 

2.  Yes, Medicare (CMS) makes many of the rules which Med D insurers have to go by under their contract with Medicare - but that doesn't mean that the insurers don't influence these decisions especially if it saves them and Medicare money.  But safety concerns are also part of the decision especially prior authorizations and quantity limits - opioids come to mind here.

  • prior authorizations
  • step therapy
  • quantity limits

I did not know that meds that required a PA wasn't the same between insurers as long as the med is on their respective  formulary - at least the ones where there is a safety concern, i.e. opioids. 

 

However, CMS, because of Covid-19, has already given the insurers permission to loosen some of these guideline.

HHS - CMS DATE: April21, 2020(rev. from March 10, 2020) TO: All Medicare Advantage Organizations, Pa... 

 

See Page 6 - Part D Sponsors

Section 1860D-4(b)(1)(C)(iii) of the Social Security Act requires that the Secretary’s rules on pharmacy network access “include adequate emergency access for enrollees.” Using that authority, CMS has previously provided information to Part D sponsors5 about their ability to take certain actions in response to disasters or emergencies that are reasonably expected to result in disruption in access to covered Part D drugs, which potentially could now include COVID-19. Part D sponsors may also take the following actions to ensure pharmacy access during a disaster or state of emergency resulting from COVID-19.

 

Then down to:

Prior Authorization for Part D Drugs  As is the case for Medicare Advantage Organizations, consistent with flexibilities available to Part D Sponsors absent a disaster or emergency, Part D Sponsors may choose to waive prior authorization requirements at any time that they otherwise would apply to Part D drugs used to treat or prevent COVID-19, if or when such drugs are identified. Sponsors can also choose to waive or relax PA requirements at any time for other formulary drugs in order to facilitate access with less burden on beneficiaries, plans, and providers. Any such waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency. We encourage plans to consider utilizing this flexibility.

 

However, if the med involves an opioid or some other safety measure med, it is covered under Cost and Utilization Management Requirements and  "Safety Edits" beginning on page 7.

 

This (permission to alter for an emergency) will last as long as there is a need because of Covid-19 but a lot of it is left up to the particular insurer as to how they waive some of the requirements.  For meds with a safety issue - don't expect too much.

 

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@GailL1 wrote:

@aruzinsky wrote:

1. Every Physician should display a list of Medicare Advantage plans to which they are an in- network provider.

 

 

2. Prior authorization of drugs should be between the patient and Medicare instead of between the patient and the insurance company.

 

 

 


1,  Yes, this is confusing and has gotten a lot worse since many hospitals have now bought out physician practices.  Best thing to do is call and talk to the insurance processor in your physicians office - the individual physician probably doesn't know.  

 

This would be a good suggestion to get to Medicare (CMS) and send a copy of your letter to your US House Rep. 

 

When they were just combined in a group of physicians, each one could have different coverage options within the group.  I don't know if that is the case if the WHOLE group is now owned by some medical conglomerate.

 

2.  Yes, Medicare (CMS) makes many of the rules which Med D insurers have to go by under their contract with Medicare - but that doesn't mean that the insurers don't influence these decisions especially if it saves them and Medicare money.  But safety concerns are also part of the decision especially prior authorizations and quantity limits - opioids come to mind here.

  • prior authorizations
  • step therapy
  • quantity limits

I did not know that meds that required a PA wasn't the same between insurers as long as the med is on their respective  formulary - at least the ones where there is a safety concern, i.e. opioids. 

 

However, CMS, because of Covid-19, has already given the insurers permission to loosen some of these guideline.

HHS - CMS DATE: April21, 2020(rev. from March 10, 2020) TO: All Medicare Advantage Organizations, Pa... 

 

See Page 6 - Part D Sponsors

Section 1860D-4(b)(1)(C)(iii) of the Social Security Act requires that the Secretary’s rules on pharmacy network access “include adequate emergency access for enrollees.” Using that authority, CMS has previously provided information to Part D sponsors5 about their ability to take certain actions in response to disasters or emergencies that are reasonably expected to result in disruption in access to covered Part D drugs, which potentially could now include COVID-19. Part D sponsors may also take the following actions to ensure pharmacy access during a disaster or state of emergency resulting from COVID-19.

 

Then down to:

Prior Authorization for Part D Drugs  As is the case for Medicare Advantage Organizations, consistent with flexibilities available to Part D Sponsors absent a disaster or emergency, Part D Sponsors may choose to waive prior authorization requirements at any time that they otherwise would apply to Part D drugs used to treat or prevent COVID-19, if or when such drugs are identified. Sponsors can also choose to waive or relax PA requirements at any time for other formulary drugs in order to facilitate access with less burden on beneficiaries, plans, and providers. Any such waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency. We encourage plans to consider utilizing this flexibility.

 

However, if the med involves an opioid or some other safety measure med, it is covered under Cost and Utilization Management Requirements and  "Safety Edits" beginning on page 7.

 

This (permission to alter for an emergency) will last as long as there is a need because of Covid-19 but a lot of it is left up to the particular insurer as to how they waive some of the requirements.  For meds with a safety issue - don't expect too much.


"Part D Sponsors may choose to waive prior authorization requirements at any time that they otherwise would apply to Part D drugs used to treat or prevent COVID-19, if or when such drugs are identified."

 

This is evidence that Medicare makes PA requirements for drugs because, if the insurance company made the PA requirements, the insurance company wouldn't need Medicare's permission to change PA requirements.  It follows that the same drugs require PA across all plans that offer the drugs.  If Medicare determines which drugs require PA, Medicare should do the PA for those drugs to promote competition between insurance companies.

 

The DEA assigns Schedule numbers to drugs according to safety and effectiveness, the lower the number, the more dangerous and ineffective.  Schedule I drugs, e.g., heroin, are illegal.

Inexpensive Schedule II opioids, e.g., fentanyl and methadone, require a written prescription but don't require PA.  Pentazocine/naloxone, which is Schedule IV, requires a prescription that can be phoned to the pharmacy but it requires PA because it is expensive and some medical organization (I forget the name) claimed it was dangerous for seniors without citing any scientific evidence.

 

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@aruzinsky   Prior authorization of drugs should be between the patient and Medicare instead of between the patient and the insurance company.

 

If Part D was managed by Medicare your suggestion would be logical.

 

But with exception of Part B covered drugs, your Part D coverage is managed by an insurance carrier. It doesn't matter if your plan is a stand alone Part D plan or one that is baked into an Advantage plan.

 


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@somarco wrote:

@aruzinsky   Prior authorization of drugs should be between the patient and Medicare instead of between the patient and the insurance company.

 

If Part D was managed by Medicare your suggestion would be logical.

 

But with exception of Part B covered drugs, your Part D coverage is managed by an insurance carrier. It doesn't matter if your plan is a stand alone Part D plan or one that is baked into an Advantage plan.

 


Part D is a contract between Medicare (CMS) and the insurance company therefore Medicare can impose whatever terms it wants in the contract.

 

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@aruzinsky Part D is a contract between Medicare (CMS) and the insurance company therefore Medicare can impose whatever terms it wants in the contract.

 

You need to take a Mulligan on that one, Sparky.

 

Part D is a contract between the carrier and the policyholder.


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@somarco wrote:

@aruzinsky Part D is a contract between Medicare (CMS) and the insurance company therefore Medicare can impose whatever terms it wants in the contract.

 

You need to take a Mulligan on that one, Sparky.

 

Part D is a contract between the carrier and the policyholder.


Wrong as always.

 

https://medicareadvocacy.org/medicare-info/medicare-part-d/

 

"That is, Medicare contracts with private companies that are authorized to sell Part D insurance coverage. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. In order to have Part D coverage, beneficiaries must purchase a policy (i.e., enroll in a plan) offered by one of these companies."

 

Even without reading the above, anyone but an idiot would know that a contract requires consideration.  Consideration in contract law is simply the exchange of one thing of value for another.  For policies with zero premium, as is the case for many Medicare Advantage plans, there is no consideration given by the policy holder to the insurance company therefore there is no contract between them.

 

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 electrical engineer

 

This explains a lot.

 

 

 

 


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@somarco wrote:

 electrical engineer

 

This explains a lot.


You are correct, for a change.  Electrical engineers are responsible for all of the electronic devices that ingrates, such as you, take for granted.  Thanks to electrical engineers, TVs are better and cheaper than they were 60 years ago.  No other profession can make a similar claim of providing better and cheaper goods or services, especially professions in the insurance and health care industries.

 

 

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