Medicare Compliance & Reimbursement

You know that a patient who's new to a Part D prescription drug plan (PDP) has rights -- but an understanding of the fine print is what will help you ensure the patient gets the medication he needs in the coming year.

Background: Part D's "open enrollment" period for the 2008 plan year kicks off Nov. 15 and runs through Dec. 31. That means that all Part D beneficiaries are now eligible to join, switch or drop their Medicare drug coverage.

Once this open enrollment period ends, most Medicare patients are locked into their current plan until the end of the year.

Part D plans are required by law to establish an appropriate transition process for enrollees who are moving to a Part D plan from other prescription drug coverage, notes attorney Anne Hance with McDermott, Will & Emery in Washington, DC. Medicare transition requirements also protect beneficiaries moving from one Part D PDP to another.

Impact: During last year's open enrollment, about 10 percent of the participants changed plans, according to the Centers for Medicare & Medicaid Services (CMS). But count on many others being affected during the transition to the new plan year.

Example: Beneficiaries who were granted an exception for a certain drug in 2007 could lose their coverage in 2008. Why? The PDP's exception may expire with the end of the plan year, since plans have no legal obligation to carry over an exception, counsels Vicki Gottlich of the Center for Medicare Advocacy in Washington, DC.

The transition is also likely to be rough for low-income beneficiaries who face "automatic" transfers to other plans. For 2008, fewer plans have premiums below the "benchmark," meaning fewer are eligible for auto-assignment of dual-eligible beneficiaries.

Big shift: CMS has announced that it expects that substantially more beneficiaries across the country will have to switch plans in 2008 -- 1.6 million beneficiaries as compared to just 250,000 beneficiaries in 2007.