ARLINGTON, Va. — The National Association of Chain Drug Stores has called on the Centers for Medicare & Medicaid Services (CMS) to assist consumers newly enrolled in plans bought via the health insurance exchanges as they access their prescription drug benefits.
NACDS said that this week it sent a letter to CMS administrator Marilyn Tavenner suggesting administrative changes "to facilitate a smooth start for new exchange enrollees seeking prescription drug coverage in the 2015 plan year."
"We recommend that exchange call centers remain open on all federal and state holidays during the December/January period, that exchange plan beneficiary eligibility files are updated on a nightly basis, and that functionality is implemented to allow pharmacists to use one-time overrides in the month of January where they have difficulty adjudicating claims for new exchange enrollees," NACDS wrote to Tavenner.
NACDS detailed the technical rationale for each of its recommendations, with a focus on optimizing the experience of patients.
"The first few days of coverage during a new plan year are the days in which confusion and transitional problems are most likely to occur. Accordingly, to help beneficiaries have a more positive experience, state run call centers should be accessible to patients and pharmacists on state and federal holidays for beneficiaries that are experiencing difficulty using their prescription benefits for the first time in January 2015," NACDS explained.
The association also said that, as in 2014, it’s concerned that in the 2015 plan year patients may visit their pharmacy in January, shortly after enrolling in a plan, only to find that their coverage is not yet active.
"Such scenarios are most likely to occur as a result of the failure of plans to provide nightly updates to the patient eligibility files," NACDS noted. "To provide for a smooth transition from coverage to care at the start of the 2015 plan year, we request that CMS require plans to provide nightly updates to patient eligibility files."
Also at the start of a plan year, there’s often confusion concerning coverage for specific medications for new plan enrollees, NACDS said in the letter, adding that difficulties in adjudicating these drug claims can result in continuity of care problems as patients are delayed or denied access to the medications they need.
"To promote continuity of care and avoid potential costly repercussions from patients not having access to the medications they need, we request that CMS allow pharmacies one-time overrides of prescription drug claim denials during the month of January 2015," the association wrote. "CMS should further make clear that the plans have the responsibility for paying for the overridden claim once the claim is approved. This will provide patients with access to the drugs that they need while they work through coverage issues with their insurer, or work with their prescriber to find a substitute covered medication.
NACDS added that its recommendations reflect its engagement in late 2013, when the association advised CMS of steps necessary to improve the Jan. 1, 2014, rollout of exchange-based insurance coverage as a result of the Affordable Care Act.
