Level 3, Course 3: Part D Appeals



Online SHIP Counselor TrainingLevel 3, Course 3: Part D AppealsSlide 1: Title slideHello and welcome to the third course in Level 3 of the Online SHIP Counselor Training core curriculum: Part D appeals. Remember, you can pause this course at any time and review any part of it at your convenience. Feel free to take the Course 3 quiz after this course to review what you learned. Each course also includes supplementary materials and a case study that you can use to reinforce key concepts. Now, let’s begin. Slide 2: What you will learnIn this course, you will learn about Medicare Part D appeals. The process for Part D appeals is the same whether a person has a stand-alone Part D plan (PDP) or a Medicare Advantage Plan with prescription drug coverage (MAPD).After taking this course, you will be able toOne: Identify when a beneficiary may start an appealTwo: Explain the difference between standard and expedited appealsThree: Understand the steps in the different appeal processesFour: Help clients through all the steps of a Part D appealThe supplementary materials section includes a Part D appeal chart. Note that beneficiaries may come to SHIP counselors for assistance with their appeals. SHIP counselors can assist beneficiaries, for example, by researching applicable coverage rules or suggesting content for appeal letters. While each appeal is different depending on the service and the type of Medicare coverage, these courses aim to provide a general outline so that you have an understanding of the different steps. The names of the notices and the entities involved may be different, but the steps in the process follow similar patterns. Slide 3: Medicare Part D appeal A Medicare Part D appeal is a formal coverage or payment request beneficiaries make to their Part D plan if they disagree with their plan’s coverage or payment decision about a prescription drug they need. We will talk about situations in which beneficiaries may want to consider starting a Part D appeal in a few minutes. Part D appeals can follow either a standard timeline or an expedited timeline. The steps of the appeal process are the same for both. The difference is that standard appeals work on a less urgent timeline than expedited appeals. A beneficiary can request an expedited appeal if they or their doctor feel that their health could be seriously harmed by waiting the standard timeframe for appeal decisions. Generally, beneficiaries have to make a request to their Part D plan to have their appeal expedited and explain why they would be harmed by the standard timeframe. A beneficiary’s doctor can file an expedited appeal on the beneficiary’s behalf. Beneficiaries should get their doctor to support their expedited request if they are filing the appeal on their own. Slide 4: Part B- and Part D-covered drugsAs you learned in Level 2: Medicare Coverage Rules, Part B and Part D cover outpatient prescription drugs under different circumstances. In general, Part B covers drugs that can typically be administered only by a beneficiary’s doctor or health care provider. Part D generally covers self-administered outpatient drugs. You can refer to the Part B vs. Part D flier in the supplementary materials section for more information about Part B-covered drugs.The part of Medicare under which a service is covered determines the appeal process if that service is denied. If a beneficiary’s Part B-covered drug is denied at the pharmacy, then they file an Original Medicare or Medicare Advantage appeal, depending on their coverage. If a beneficiary’s Part D-covered drug is denied, then they file an appeal according to the Part D appeal process. ???In this course you will learn about the appeal process for Part D coverage denials. It is important to remember that these appeals only apply to Part D-covered drugs, not any prescription medication that has been denied.Beneficiaries may encounter certain problems related to coverage of a Part B or Part D drug. Let’s say a beneficiary has Original Medicare and a stand-alone Part D plan. If the beneficiary’s Part B-covered drug is denied at the pharmacy, it could be because the prescription was billed to the stand-alone Part D plan and not to Original Medicare. The beneficiary does not have to appeal for coverage, and fixing this issue is a matter of submitting the claim to the correct entity. This is more common for beneficiaries who have a stand-alone Part D plan, but can also happen to beneficiaries enrolled in a Medicare Advantage Plan.Slide 5: Before filing a Part D appealBefore we discuss the different levels in the Part D appeal process, let’s talk about what happens first.Usually, a beneficiary first learns that there is a problem when a pharmacist tells them that their plan will not cover their medication, and that they can pay out of pocket if they want the drug that day. The pharmacist may tell them that the plan will not cover the drug and that they have to pay out of pocket if they wish to get the drug that day. The beneficiary should be given a notice about what they can do next. This notice is not personalized and does not give any specific information about why the plan is denying coverage, but rather directs beneficiaries to contact their plan and provider for more information. There are a few reasons why Part D plans will not pay for medications. Sometimes, the reason is that the beneficiary is requesting a refill too soon. The pharmacy can usually correct this if there is a reason that the beneficiary needs the prescription before their current supply is depleted. This could be the case if the beneficiary is planning to travel and won’t have access to a pharmacy. It is a good idea for beneficiaries to ask the pharmacist whether they can identify this kind of problem and help fix it. It could be that the plan will not pay for the medication because the drug is not listed on the plan’s formulary, which is a list of drugs that a plan covers. If the medication is not on the plan’s formulary, the plan does not have to cover that drug unless the beneficiary cannot take any of the formulary alternatives. Similarly, the plan may not pay for the drug because it is subject to utilization management tools, like prior authorization, step therapy, or quantity limits. Prior authorization requires beneficiaries to get prior approval from their plan before it will cover a specific drug. Quantity limit means that the plan will only cover a certain amount of a drug over a certain period of time, such as 30 pills per month. Step therapy requires beneficiaries to try a cheaper drug before the plan will cover a more expensive prescription. If a beneficiary does not meet the requirements for coverage, the plan usually does not have to cover the drug, unless the beneficiary can show, through an appeal, that there is a good reason they do not meet the requirements.Lastly, the plan may not pay for the medication if it is not a Part D drug, meaning that it cannot be covered by any Part D plan. Examples of non-Part D drugs include medications for weight loss and gain, drugs that treat the symptoms of cough and colds, generally over-the-counter medications, and medications that are prescribed for a use that is not approved by Medicare, called an ‘off-label’ prescription. A coverage denial at the pharmacy is one situation that may occur before a beneficiary starts an appeal. Another is when a beneficiary goes to the pharmacy and discovers that while their plan covers their drug, they have to pay a higher cost-sharing amount. First the beneficiary should check to see if their pharmacy is in network. A beneficiary will pay more for their prescription from a pharmacy that is not in their plan’s network.If the pharmacy is in network and the prescription is still very expensive, this could be because the medication is on a higher tier of coverage than other drugs. Part D plans use tiers to categorize drugs. Higher tiers are more expensive and have higher cost-sharing amounts. If this is the case, the beneficiary can use the Part D appeals process to request lower cost sharing if they cannot take the medications for their condition that are on the lower tier. This is called a tiering exception.Slide 6: Before filing a Part D appealAs we just discussed, there are many reasons why a beneficiary may have been denied coverage at the pharmacy. Before starting an appeal, the beneficiary should contact the plan to find out why it did not cover their drug. This is an important step because the beneficiary needs to find out whether the plan made an administrative error, or if the plan wouldn’t pay for the drug because of formulary or coverage rules. The beneficiary should write down the name of who they speak to, the date and time of their call, and the outcome of the call. The beneficiary should also get in touch with their doctor. The doctor may be able to contact the plan to try to resolve the issue. For example, the doctor may be able to provide needed information, such as medical records that show that a person has tried the step-therapy drug required and had a negative reaction to it. This would justify coverage. If the beneficiary wishes to appeal the plan’s decision because no other resolution is found, it is important that they enlist the help and support of the prescribing provider or another health care provider familiar with their medical history in order to add medical validity to the appeal. Beneficiaries may also come to SHIP counselors for assistance with their Part D appeals. Next, the beneficiary files a formal coverage request with their Part D plan. This is not actually an appeal—it is asking the plan to formally state the decision that it made through the pharmacy. The beneficiary is requesting a coverage determination. If the beneficiary requests that the Part D plan make an exception to a rule, such as cover an off-formulary drug or cover a medication without prior authorization, this can also be called an exception request. You may hear exception request and coverage determination used interchangeably. A beneficiary cannot begin an appeal until they have requested a coverage determination and received a written decision from the plan about whether it will cover their drug. The plan should issue a decision within 72 hours of getting the beneficiary’s request. If the request is expedited, the plan should issue a decision within 24 hours of getting the beneficiary’s request. As previously noted, the beneficiary can also ask their doctor to request an expedited appeal on their behalf, and show that their health would be at risk if they were to adhere to the standard deadlines. A Part D plan must agree to a doctor’s request to expedite the process, but may require prior approval if the beneficiary makes the request. The steps are the same for non-expedited and expedited appeals, but the timeframes differ. A few more things to keep in mind: even if a beneficiary is requesting their own coverage determination, their doctor may need to fill out a form or provide the plan with more information. SHIP counselors should advise beneficiaries to keep copies of anything they mail out and to keep copies of correspondence, such as fax transmission reports or certified return receipts. Beneficiaries can also ask for a coverage determination by calling their plan, but some plans may still require that the doctor submit a written statement of support and may not process the request until the doctor has provided this information. Even if the plan does not require it, the beneficiary or their doctor may want to send the Part D plan medical records that support the request. Next, the beneficiary receives the coverage determination, which is the plan’s decision about paying for the drug. If the plan denies coverage, the beneficiary can officially start an appeal. There is a sample coverage determination form in the supplementary materials section of this course. If the plan decision is favorable, the beneficiary should be able to get the drug. Plans sometimes notify beneficiaries of a favorable coverage determination by phone, and always notify them in writing. The beneficiary should confirm that the plan will cover their drug for the rest of the year, if not for the rest of the time they have drug coverage under that plan, by contacting the plan and getting the approval in writing. If the beneficiary requested a tiering exception and the plan agrees to move their drug to a lower tier, then they should expect to pay a lower copay when they pick up their drug at the pharmacy.If the plan’s decision is unfavorable, the plan sends the beneficiary a Notice of Denial of Medicare Prescription Drug Coverage, and the beneficiary can start an appeal. The Notice of Denial of Medicare Prescription Drug Coverage is the official, written denial notice from the Part D plan. Receiving this notice and responding to this notice starts the Part D appeal. If the plan does not respond to the request for a coverage determination within the specified timeframe, that is, within 72 hours for a standard request or 24 hours for an expedited request, this count as a denial and the beneficiary can start an appeal. Slide 7: Level 1: Plan Redetermination The first level of appeal is Plan Redetermination. As previously noted, once the beneficiary has received the Notice of Denial of Medicare Prescription Drug coverage, they can start their appeal. First the beneficiary has 60 days from the date listed on the notice to file their appeal with the Part D plan, regardless of whether their appeal is under standard or expedited review. Beneficiaries must follow instructions on the notice. If a doctor is not appealing on their behalf, they may want to ask their doctor to write a letter of support addressing the plan’s reasons for not covering the drug (or lowering the tier) as they are described in the Notice of Denial of Medicare Prescription Drug Coverage. Next, plan staff that was not part of the coverage determination review the appeal and other evidence such as the beneficiary’s medical history, treatment records, and any statement the beneficiary has made. Then they decide if the plan will cover the drug. Under a standard timeline, the plan should issue a decision within seven days of getting the initial appeal. If the plan has approved the request for an expedited review of the appeal, it must issue a decision within 72 hours of getting the appeal. There are two possible outcomes:A favorable decision and the plan agrees to cover the drug.An unfavorable decision and the beneficiary can move to the next level of appeal. Slide 8: Level 2: IRE ReconsiderationThe second level of appeal is called IRE Reconsideration. An Independent Review Entity, or IRE, is contracted by Medicare to review Part D appeal cases at the second level. The IRE may be referred to as the Part D Qualified Independent Contractor (Part D-QIC) or another name, such as the name of the company that has the contract. Contact information is included in the supplementary materials. First the beneficiary files an appeal with the IRE within 60 days of the date listed on the unfavorable plan redetermination notice. Instructions on how to file an appeal, who to speak to, and where to send the appeal should be listed on the notice. Next, the IRE reviews the case and decides whether the plan should cover the prescription drug or allow the tiering exception. The IRE should issue a decision within seven days of getting the appeal. If the beneficiary is appealing on an expedited timeline, the IRE must issue a decision within 72 hours of getting the appeal. There are two possible outcomes:A favorable decision and the plan agrees to cover the drug.An unfavorable decision and the beneficiary can choose to move to the next level of appeal.Slide 9: Level 3: ALJ Hearing The third level of appeal is the Administrative Law Judge, or ALJ, Hearing. Once the beneficiary receives an unfavorable IRE decision letter that indicates that the plan will not cover the drug, they can request a hearing with the ALJ within 60 days. The beneficiary requests this by following instructions on the IRE decision letter. The beneficiary may want to solicit the help of a lawyer (or local legal services organization) at this level of appeal, but they are not required to do so and can still appear at the hearing by themselves. They can also appear with other representatives such as family members, or receive assistance from a SHIP counselor. Generally, in order to request an ALJ hearing, the beneficiary must submit a written request to the appropriate Office of Medicare Hearings and Appeals, or OMHA, listed on their unfavorable IRE decision letter notice. OMHA has five field offices throughout the United States. The beneficiary should make sure they send the request to the address listed on the notice and follow directions carefully, since failure to do so will delay processing. The written request can either be made with a CMS Request for Medicare Hearing by an Administrative Law Judge form or a beneficiary’s own written request. The beneficiary should note on the envelope that it is a beneficiary appeal. They can do this by including “Attn: Beneficiary Mail Stop” to the address to which they send their appeal forms. A copy of a sample request letter is included in the supplementary materials section of this course.Note that the ALJ reviews the appeal only if the non-covered service or item is worth at least the amount indicated on the IRE decision letter. This amount, called the amount in controversy, changes each year and should be indicated on the IRE decision letter that the beneficiary receives. For Part D appeals, a beneficiary can meet the amount in controversy by using the combined amount of their out-of-pocket costs from filling the prescription and the number of refills on the prescription. Upon receiving the request, the ALJ reviews the claim and sets the time and place for the hearing. The beneficiary receives a Notice of Hearing that includes information on the date and time of their hearing. They will receive this information at least 20 days before the actual hearing. The beneficiary will also be asked to complete a Response to Notice of hearing form and return it within five days to the address listed on the notice. The hearing can be dismissed if the beneficiary fails to appear without good cause. To review good cause extensions, please refer to Level 3, Course 1: Original Medicare Appeals.Next, the beneficiary attends the hearing. In most cases, a hearing is held by video teleconference. Hearings may also be held over the telephone or in person, depending on the circumstances. During the hearing, the ALJ may question the beneficiary and any witnesses they bring to the hearing. The ALJ may ask health care experts to join the hearing for medical support or evidence pertaining to the case. Likewise, the beneficiary or their representative can question these personnel as well. The Part D plan may or may not attend the hearing.Lastly, the ALJ notifies the beneficiary of its decision. This decision is usually mailed to the beneficiary, and they generally receive the decision within 90 days of the ALJ receiving the hearing request. Keep in mind that there can be significant delays at this level and that this timeframe may be extended in certain circumstances. There are three possible outcomes of an ALJ hearing: A favorable decision and the Part D plan should cover the drug. An unfavorable decision and the beneficiary can choose to move to the next level of appeal.The ALJ does not issue a decision within 90 days, and the beneficiary can move to the next level of appeal. If this is the case, it may be helpful for the beneficiary to speak with an attorney. The beneficiary should consider that they will not have a hearing opportunity at the next level. Often, it makes sense to wait for the ALJ decision before deciding whether or not to appeal to the next level. Slide 10: Level 4: Medicare Appeals Council ReviewThe Medicare Appeals Council reviews the fourth level of Part D appeals.If the ALJ affirms the IRE’s denial, the beneficiary can request a MAC review within 60 days of receiving an unfavorable ALJ decision. The request must usually be in writing, and should address the parts of the ALJ decision with which the beneficiary disagrees.Remember, beneficiaries will most likely want to request an attorney or get help from a legal services organization at the level of the MAC review.Next, the MAC reviews the ALJ decision and decides whether the plan should cover the service or item in question. The MAC has 90 days to issue a decision. Unlike the ALJ Hearing, the MAC Review is carried out in writing. The beneficiary does not have to attend a hearing. There are three possible outcomes:A favorable decision and the Part D plan should cover the drug.An unfavorable decision and the beneficiary can choose to move to the next and final level of appeal.The MAC does not make a decision within 90 days, and the beneficiary can request that the appeal be forwarded to Judicial Review.Slide 11: Level 5: Judicial ReviewJudicial Review is the fifth level of Part D appeals. First, the beneficiary requests Judicial Review in their local U.S. Federal District Court. The beneficiary must file their request with the Federal District Court within 60 days of receiving the unfavorable Medicare Appeals Council decision. Keep in mind that the Federal District Court will only consider the appeal if the cost of the prescription drugs meets the annual minimum threshold. This amount is determined yearly, is indicated on the MAC decision, and is larger than the amount in controversy for ALJ hearings. There are many requirements for filing a case in Federal District Court. A beneficiary does not just write a letter as in the other levels of appeal. It is usually a good idea to obtain the assistance of an attorney to appeal at this level.Next, the court reviews the case and decides whether the plan should cover the prescription drug.There are two possible outcomes:A favorable decision and the court order the plan to cover the drug.An unfavorable decision and the beneficiary will have to pay for the drug. Slide 12: Case example: Pharmacy denial Let’s use the case example of Noor to review the main steps of appealing a Part D plan’s coverage or payment decision on a prescription drug. Noor went to her local pharmacy to fill a new prescription that her doctor had prescribed. Her pharmacist gave her a notice called “Medicare Prescription Drug Coverage and Your Rights” and also told her that the drug she needed was not listed on her Part D plan’s formulary. Noor needs this drug immediately. What can she do to get the drug she needs?Answer: Noor should contact her doctor about this issue as soon as possible. Her doctor may help her get the drug by requesting an exception to the plan’s rules. Alternatively, her doctor may prescribe a similar drug that is covered by her Part D plan, allowing her to avoid the appeal process. Noor can also request a formulary exception on her own. She should contact her Part D plan directly to get the address to which to send her request, or to find out how to make the request over the phone. No matter what, Noor should still be in contact with her doctor, since he will need to write either a letter of support or complete a form to verify that the drug Noor needs is medically necessary. If Noor makes her exception request in writing, she will need to send her plan a letter of support or a Coverage Determination Request form in addition to her Exception Request. Note that Noor may be able to pay out of pocket for the drug when she is at the pharmacy and get reimbursed by her Part D plan if she appeals. If Noor’s Part D plan sends her a written denial in response to her or her doctor’s coverage request, she can begin her appeal by following directions on her Part D plan’s denial decision.Slide 13: Tips for appealingSHIP counselors may be called upon to help beneficiaries with their appeals, so it is helpful to keep some of these tips in mind. The first tip is to encourage beneficiaries to follow instructions. Beneficiaries receive important notices from their Part D plans and their pharmacies that contain the rules on how to appeal. Notices include information about what numbers to call and where to mail key appeal-related documents. Also remember that appeals will be handled more quickly at some levels if they are labeled as being from a beneficiary. This can be written on the appeals forms and/or any envelopes mailed to entities throughout the appeals process. Next, counselors should be sure to help beneficiaries adhere to important deadlines. There are always deadlines when beneficiaries appeal. These timelines vary depending on what health care service they are appealing. The time in which beneficiaries have to file an appeal should be indicated on the Medicare notices they receive. If they try to appeal beyond the specified deadline, they will most likely not be able to appeal unless they qualify for a good cause extension as mentioned earlier. Good cause extensions apply at each level of the Medicare appeal process and are evaluated on a case-by-case basis. Counselors should advise beneficiaries to keep original copies of any information they send out or receive. Administrative errors can occur, so it is important that beneficiaries have copies of all appeal documents for their own records. Also remember that you or the beneficiary can call Medicare or the entity listed on the notice they receive to ensure that they received the appeal. Let beneficiaries know that they should take thorough notes while they are appealing. If they appeal over the phone, they should write down the date and time they call, the name of the representative they speak to, and the outcome of the call. If they speak to their doctor or send out any information, they should write this information down. Appeals can be straightforward if beneficiaries have specific and well-documented information to refer to. Help beneficiaries strengthen their appeal by suggesting they get a doctor or health care provider’s support in the appeal process. A doctor’s letter of support is always helpful and may add medical validity to the appeal. SHIP counselors can also help by letting beneficiaries know the kind of information that it is helpful for providers to include in their letters, for instance why the drug is prescribed and whether other drugs have been tried. Lastly, keep going! The appeal process has many levels. Slide 14: What you have learned This concludes Course 3: Medicare Part D Appeals in Level 3 of the Online SHIP Counselor Training core curriculum.In this course, we learned about Medicare Part D appeals, the type of appeal a beneficiary makes to their Medicare Part D plan if they disagree with the plan’s coverage or payment decision on a needed drug.We also talked about when beneficiaries might want to appeal. Specifically, we said that beneficiaries can start an appeal if:The drug they need is not covered by their Part D plan.The drug is covered, but there are coverage restrictions on the drug, such as prior authorization, quantity limits, or step therapy.The drug is covered, but they want to request a tiering exception and pay a lower copay for the drug they need. We then learned specifics about how to file a Part D drug appeal, including the first pre-appeal step of filing an Exception Request with the Part D plan. We then explored the five levels of appeal and the steps the beneficiary must follow, timeframes, and possible outcomes. Throughout this course, we emphasized the importance of getting a doctor’s support when challenging a Part D plan’s coverage or payment decision on a drug. Finally, we reviewed some tips that SHIP counselors can use to help their clients move effectively through the appeal process. Remember, beneficiaries have the right to appeal any time their Medicare prescription drug plan denies coverage or payment on a prescription drug they need. Slide 15: End slide Thank you for your attention throughout this course. Remember that you can always go back to review course information at any time. Please feel free to take a look at the supplementary materials section for helpful handouts and fliers that will enrich your Medicare learning. You can also take the short quiz for this course to help you review and practice the Medicare information you just learned. ................
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