During Medicare’s annual Fall Open Enrollment Period that begins October 15 and ends December 7 (not to be confused with the October 1 start of open enrollment in the health insurance marketplaces established by the Affordable Care Act), people with Medicare can change their Medicare health and drug coverage options such as their Part D plan.
These weeks present an opportunity for pharmacists to continue to build relationships with their patients. Pharmacists can remind patients of the dates, talk to patients about what services pharmacists provide, make sure Medicare patients receive medication therapy management (MTM) and “star” ratings information from Part D plans, and explain MTM to patients.
“Encourage patients to ask questions about the benefits included in their plan,” said Stacie Maass, BSPharm, JD, APhA Senior Vice President of Pharmacy Practice and Government Affairs. “Many patients are eligible for MTM but are unaware of the benefit or do not take advantage of it. Patients who take advantage of their MTM benefit are overwhelmingly happy with the service.”
The growing importance of MTM was emphasized in CMS’s advance notice and call letter for 2014—an annual guidance document for Medicare Advantage and Part D prescription drug plans that was released April 1. In the guidance, CMS also outlined a policy for avoiding fraud, waste, and abuse in mail-order services. In addition, the Part D “donut hole” will continue to close gradually in 2014.
Medicare health and prescription drug plans are rated on their performance on a scale of one star (“Poor”) to five stars (“Excellent”). The overall star ratings are available at Medicare.gov/find-a-plan. These star ratings can be used to compare plans to find the best plan for the patient. “Star ratings should be highlighted in the discussion with the patient,” said Jillanne Schulte, JD, APhA Director of Regulatory Affairs. In the guidance for 2014, CMS reported that it is aware of high-performing plans using MTM services to improve their Part D star ratings.
Of note, Medicare patients can switch to a Medicare prescription drug plan rated five stars during a 5-Star Special Enrollment Period from December 8, 2013, to November 30, 2014, according to the 2014 Medicare & You handbook. Patients can only switch to a five-star plan if one is available in their area, and can only use the Special Enrollment Period once during these dates.
CMS will continue to promote beneficiaries’ awareness of MTM services through the 2014 Medicare & You handbook, on Medicare.gov, through the new MTM tab on the plan finder, and the requirement that plans have a dedicated “Medication Therapy Management Program” page linked from the Medicare drug plan website.
In the guidance for 2014, CMS encouraged Part D plans to require mail-service and community pharmacies to obtain patient consent to deliver a new or refill prescription, before each delivery, including refills or new prescriptions received directly from the physician. The new policy doesn’t apply when the patient actively requests the new prescription or refill, according to Schulte.
While the idea is to avoid fraud, waste, and abuse from unnecessary refills, APhA recommended in March 1 comments on the draft guidance that CMS consider additional steps in which a patient or caregiver could select their own preferences for use of an auto-refill or ship program to avoid generating too many phone calls to the patient.
The Part D donut hole will continue to close gradually under the Medicare Coverage Gap Discount Program in the Affordable Care Act. In 2014, Medicare patients in the donut hole (who don’t qualify for the low-income Extra Help program) will pay 47.5% of the cost for brand-name drugs and 72% of the cost for generic drugs.