Medicare Compliance & Reimbursement

'We make no excuses,' says HHS.

The ashes are still falling in the aftermath of Medicare's drug plan rollout. Fortunately, the Department of Health and Human Services is not remiss about its role in cleaning up the mess.

HHS Secretary Mike Leavitt issued a Feb. 1 progress report that outlines Part D's current problems and the department's plans to resolve them--but not before the report makes meager attempts to highlight the plan's small successes.

The list of successes is noticeably shorter than the list of problems that HHS needs to address. Seniors and taxpayers are saving money, and beneficiaries are receiving better health care, Leavitt maintains. Anecdotes about enrollees and pharmacists pepper Leavitt's report and add notable color to his claims.

Success Is Still 9 Steps Away

Medicare's goal was to enroll between 28 and 30 million people in the new drug plan during 2006; so far, more than 24 million benes have enrolled in the plan with hundreds of thousands more enrolling each week. In addition, drug plans are successfully filling millions of prescriptions each day, Leavitt asserts. But there are indeed problems.

"Any time you make a change this big in a small period of time, you have unanticipated problems," says Leavitt. To correct continuing problems that need immediate attention, HHS will use the following nine-point action plan:

1. Provide plans with up-to-date dual eligible information. Dual eligibles transitioning from Medicaid drug coverage to new Part D plans had the most enrollment problems due to incomplete enrollee information, last-minute plan switching and auto-enrollment snafus, Leavitt acknowledges. The number of people who successfully obtain their prescriptions the first time they visit the pharmacy clearly indicates the transition's success, according to Leavitt.

2. Improve data translation between Medicare, health plans and states. Data transmission glitches are to blame for many of the auto-enrollment problems that have plagued the dual eligible population, says Leavitt.

Although most enrollment data transferred correctly, communication problems between CMS' and plans' data systems prevented some benes' names and cost-sharing information from appearing. HHS is "continuing to work to improve information available to pharmacists, and it is getting better every day," Leavitt reports.

3. Reduce Medicare call-wait-times. Medicare hotline (1-800-MEDICARE) call-wait-times for pharmacists and customers were "unacceptable," says Leavitt. Additional customer support has reduced call wait-times from five minutes to less than a minute.

4. Monitor plans' call-wait-times. HHS will increasingly monitor and report on drug plans' call-wait-times, taking corrective actions as necessary.

5. Assure plans meet contractual payment terms for pharmacies. Pharmacists' efforts over the last month have been "nothing short of heroic," notes Leavitt. "I can--and will--take corrective action if a plan is not in compliance with its contractual agreements," he promises.

6. Extend transition drug coverage to 90 days. Medicare will notify plans that the 30-day transitional coverage period in effect will continue for 60 more days, extending the initial coverage period to 90 days, Leavitt says. This will give benes more time to determine their savings potential in a Part D plan.

7. Eliminate the need for state backup. By Feb. 15, states should become the "payers of last resort" for prescription drug claims. But HHS will temporarily extend state reimbursement plans on an as-needed basis, Leavitt notes.

8. Establish a reimbursement plan for states. Medicare will reimburse states for drug expenses, Leavitt reiterates in his report. "We will assume that states are paying what they have advanced on behalf of plans. If they paid higher rates or had administrative costs on top of that, we will assure they are treated fairly," he says.

9. Continue the problem-solving and improvement process. HHS is already working to address foreseeable problems that are on the horizon, including coverage for late-January enrollees and catch-up payments for enrollees who haven't made a premium payment yet this year.

Benes can facilitate a seamless enrollment process by allowing time between initial enrollment and first use of their coverage, and by enrolling early in the month, before the 15th, Leavitt suggests.

"The measure of our success should not be that we have no unexpected problems at the outset but rather that we find, fix and finish with these problems quickly so that all seniors have access to coverage that saves them money, keeps them healthier and gives them peace of mind," says Leavitt.

To view the report, visit www.hhs.gov/medicare.pdf.