JustCare

Tag: Appeals

  • New cuts proposed for Social Security Administration

    New cuts proposed for Social Security Administration

    Back in June, I reported for Just Care that Congress was keeping the Social Security Administration from spending its own money to administer benefits effectively. As a result, SSA was going to need to cut critical services. If that wasn’t bad enough, Kathleen Romig of the Center on Budget and Policy Priorities reports that there’s now a bill before the U.S. House of Representatives that calls for new cuts for the Social Security Administration in 2017.

    Since 2010, Congress has cut SSA’s core operating budget by 10 percent, after inflation, to the detriment of people needing help with their Social Security benefits. The $100 million in new cuts proposed for SSA by the House Appropriations Committee would further hurt customer service and program integrity.

    If the proposed cuts pass, it would mean that SSA would need to implement a total hiring freeze, which could:

    • Delay decisions on disability benefit appeals; the wait is already 540 days, up from 360 in 2010, or
    • Keep Social Security from hiring replacement staff as people retired or left, or
    • Require Social Security to furlough staff for one to two weeks and close its 1,245 offices in the process; 600 field offices have been forced to close since 2010, or
    • Further cut field office hours for the public, which are already cut back to a half-day on Wednesday and a 4 p.m. close every other day, or
    • Reduce staffing on the Social Security 1-800 number, meaning longer hold times for the public; hold times already average 15 minutes and 10 percent of callers get busy signals, or
    • Prevent modernization of Social Security’s computer systems

    The bill does not increase funding for program integrity by $378 million as requested and as Congress previously had agreed to do, even though Social Security returns $8 for every $1 invested in its program integrity efforts.

    If you agree that we need to expand Social Security, not make benefit or administrative cuts to it, sign this petition.

    CBPP.org
    CBPP.org
  • Insurers denying some costly treatments patients need

    Insurers denying some costly treatments patients need

    Bob Tedeschi reports in Stat news on a growing trend by health insurers to deny some costly treatments doctors say patients need and require them to try less costly treatments first. It’s called “step therapy.” The goal of keeping health care costs down is reasonable, but the consequences for some patients can be serious. (Note: If you’d like your insurer to cover whatever reasonable and necessary care your doctor recommends, sign up for traditional Medicare if you’re eligible.)

    Step therapy at its best is arguably a good thing. There is no reason for patients to get newer treatments that are more expensive when older less costly treatments are available. But, step therapy presents a serious problem when insurers use it as a way to save money even if the older less costly treatments are not working. And, insurers are becoming “more aggressive” about making patients wait long periods before insurers will cover more costly treatments.

    In some cases, doctors know that their patients need particular treatments because they have tried other treatments that have not worked. Yet, that will not stop some insurers from requiring step therapy. As a result, many states have enacted legislation to block insurers from making patients try treatments that their doctors know won’t work.

    To be clear, no one is suggesting that insurers should pay for more expensive treatments when less expensive treatments work. However, insurers should not be requiring patients to try treatments when there are risks to so doing. For example, when patients switch insurers mid-treatment, the new insurer might require their doctors to drop their current course of treatment and retry treatments that have already failed.

    What is to be done? More transparency about insurer practices is critical, including how they define whether a treatment has failed. And, insurers should not be allowed to require patients to retry treatments that have already been determined to fail. Speedy appeals of insurer denials are also needed, especially when people’s lives and well-being are hanging in the balance.

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  • If your Medicare drug plan refuses to cover your medications, take these five simple steps

    If your Medicare drug plan refuses to cover your medications, take these five simple steps

    Too often, pharmacists are unable to fill prescriptions for people with Medicare because their Part D plan says the drugs are not covered. If you need the medications, you should appeal. The drug plan may improperly believe that a less costly medication will meet your needs.  Or, the drug plan might apply inappropriate limits on your medication or not implement proper Medicare policy. Here are three things to think about when choosing a Medicare Part D drug plan.

    Almost four out of five people who appeal get their drugs covered. To file an appeal, you will need to follow a five-step process, whether you have a stand-alone Part D plan or you get your drug coverage through a private Medicare Advantage plan. Along the way, the drug plan might agree to cover your drug.

    1. If your pharmacist tells you that your Medicare Part D drug plan will not cover a drug you need, you will get a “Medicare Prescription Drug Coverage and Your Rights Notice.”
    2. Call the Part D plan and find out the reason for the denial. Unfortunately, the pharmacy cannot tell you the reason for denial. If it’s because the drug prescribed is not on the drug plan’s list of covered drugs, its “formulary,” ask your doctor if there’s another drug you can take that is on the formulary. If it’s because you must first try another drug or meet some other requirement, speak with your doctor.
    3. If you need the drug prescribed, you will need a denial letter from the drug plan. You can only appeal the drug plan’s refusal to cover a prescription if you have this letter. To get the letter, file a request for drug coverage, an “exception request” (or an expedited exception request if you need the drug urgently), along with the letter from your doctor explaining the need for the drug, with your Part D plan. Your Part D plan will let you know how to file this request. And, the drug plan might decide to cover your drug after it receives your exception request.
    4. If your Part D plan denies your exception request, it will send you a Notice of Denial of Medicare Prescription Drug Coverage. The Part D drug plan’s denial letter should explain the reason for denial. Get your doctor to explain in writing why the drug prescribed is medically reasonable and necessary and why no other drug will meet your needs. In a 2013 audit, CMS found that more than half of the health plans audited had issued inappropriate denials.
    5. If necessary, file an appeal with the Part D plan, including the letter from your doctor; file an expedited appeal if you need your drug immediately.

    So long as your drug is medically necessary, you are very likely to win the appeal. The delay you might face in getting needed medications is a problem that the Center for Medicare and Medicaid Services is now looking to address.

    Of course, even with drug coverage your out-of-pocket costs can be sky high since Congress allows the drug companies to charge whatever they want and they often have the power to set prices. And the health plans simply raise copays to offset rising costs.  They have no ability to rein in prices. It’s no surprise that 576,000 Americans had drug bills over $50,000 in 2014.

    For more information on Medicare Part D appeals, visit Medicare Interactive.