Largely driven by prior authorization, MA and Part D coverage denials leave beneficiaries with only bad options: paying out-of-pocket, going without, or getting embroiled in a daunting and deeply flawed appeals process. Each path can lead to delayed care, abandoned therapies, worse health, and higher costs. Particularly egregious are improper coverage denials, which force people to make this choice unnecessarily.
Harmful denials must be curbed, and the appeals systems must be reformed to function as a safety valve—rather than as an inadequate substitute for sound plan decisions and robust federal oversight.
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Policymakers often overlook or disregard the problems people may face when they try to enroll or stay enrolled in public programs or to get the care they need. Issues around Medicare and Medicaid enrollments and appeals are legion and can run the gamut from minor one-time annoyances to recurrent bureaucratic nightmares.
Download PDFThis report features the top helpline trends and highlights the most commonly sought helpline and Medicare Interactive answers, providing a glimpse into the various questions and needs of Medicare beneficiaries, caregivers, and the professionals assisting them in the community in 2023.
Download PDFIn 2022, Medicare Rights staff and volunteers addressed more than 27,000 questions through its national helpline and professional email channels. Additionally, Medicare Rights’ free and independent online reference tool, Medicare Interactive (MI), provided more than 2.6 million answers for beneficiaries, their caregivers, and professionals. This report features the top helpline trends and highlights the most commonly sought helpline and Medicare Interactive answers, providing a glimpse into the various questions and needs of Medicare beneficiaries, caregivers, and the professionals assisting them in the community in 2022.
Download PDFThe Medicare Rights Center (Medicare Rights) appreciates this opportunity to comment on the Advancing Interoperability and Improving Prior Authorization Processes proposed rule. Prior authorization is creating an ever-increasing burden on patients. We support many of the Centers for Medicare & Medicaid Services (CMS) provisions in this proposed rule that would reduce this burden by improving processes, timelines, access to information, and communication.
Download PDFThe Medicare Part D appeals process is an essential safety valve, allowing access to needed prescription medications—such as those that are not on the plan’s formulary, or are subject to high cost sharing, when formulary or lower cost alternatives are not appropriate. However, Part D enrollees often struggle to successfully navigate this overly complex, multi-step, process, and it can also prove burdensome for pharmacists, plans, and prescribing physicians. This can result in delayed access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs for the patient and the Medicare program.
Download PDFThe Medicare Rights Center comments on the Medicare Program; Contract Year 2024 Policy and Technical Changes proposed rule.
Download PDFImmediate action is needed to transform the nation’s drug pricing system in ways that will lower prices, strengthen Medicare, and promote the well-being of those who rely on its coverage. H.R. 3 would significantly advance these goals, in part by authorizing Medicare to negotiate prices for certain drugs; imposing inflationary rebates; and restructuring Part D to cap beneficiary out-of-pocket costs at $2,000 per year, reduce the federal government’s liability, and better align pricing incentives.
Download PDFThe Biden administration must reduce barriers to care by making coverage more available, accessible, and affordable. On our Helpline, we frequently hear from older adults and people with disabilities who live on modest or limited incomes and are struggling to access and afford their care. These financial challenges—which have in many cases been worsened by the coronavirus pandemic—along with rising health care and prescription drug costs, antiquated coverage rules, and burdensome program requirements can make it difficult for older adults and people with disabilities to obtain the care they need. The following reforms would help reduce these barriers to care by making Medicare stronger, easier to navigate, and more affordable.
Download PDFThe Medicare Rights Center (Medicare Rights) looks forward to working with the Biden administration to advance policies that protect and strengthen Medicare as well as the health and economic well-being of those who rely on its coverage. To facilitate this dialogue, we compiled a set of administrative actions for their consideration. We will also outline our legislative priorities for the 117th Congress.
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