WASHINGTON – U.S. Senators Ben Cardin (D-Md.) and John Cornyn (R-Tex.) have introduced bipartisan legislation to simplify the Part D appeals process for Medicare beneficiaries. The bill, S. 1861 – the Streamlining Part D Appeals Process Act, will cut out unnecessary steps when Medicare coverage is denied at the pharmacy counter and the beneficiary wishes to appeal the denial.
Currently, a pharmacy counter refusal does not qualify as a “coverage determination,” which a beneficiary must obtain before initiating an appeal. This means that after being refused a needed drug at the pharmacy counter and contacting her plan to learn why, a beneficiary must then work with her provider to file an exception request with her Part D plan. Only upon receipt of a written denial in response to this request—the coverage determination—is the beneficiary permitted to request a formal appeal, termed a redetermination. In other words, after being denied the coverage, a beneficiary must ask for a denial that she can then appeal. The Cardin-Cornyn bill would allow the refusal at the pharmacy counter to serve as a formal denial, eliminating several unnecessary and time-consuming steps—easing burdens on plans, providers and beneficiaries.
“Where possible, we want to strip away the extra steps that are keeping Medicare beneficiaries from getting straight answers about their Part D coverage,” said Senator Cardin. “Our goal is to streamline the ability for beneficiaries to start the appeals process as soon as possible.”
“Being denied coverage for necessary medication can be stressful, and having to navigate the convoluted Medicare appeals process is even more challenging,” said Senator Cornyn. “By simplifying this process, we can make sure Texans get timely access to needed medicine and limit bureaucratic roadblocks.”
The full text of S. 1861 can be downloaded here. The legislation is supported by the Medicare Rights Center, National Council of Aging, and Center for Medicare Advocacy.