RCPA - Rehabilitation and Community Providers Association


PCPA Supports DPW Request for Medicare Review
March 7, 2006

Secretary Estelle B. Richman of the Department of Public Welfare (DPW) wrote a letter to Administrator Mark B. McClellan of the Centers for Medicare and Medicaid Services (CMS) that requests readiness review for all Medicare Prescription Drug Plans and Medicare Advantage Special Needs Plans (SNP) prior to the termination of the 90-day transition period. PCPA, as the representative of community-based providers, responded to a request to sign on in support of the need to focus attention on Medicare in Pennsylvania. The association was pleased to be able to respond to the request and continues to address the needs of citizens dually eligible for services who have encountered difficulties in the transition to Medicare Part D.

DPW and PCPA, as well as other signatories including PANPHA, the Pennsylvania Health Care Association, the Hospital and Healthsystem Association of Pennsylvania, and the Pennsylvania Medical Society, are concerned that significant problems will arise at the end of the transition period to full implementation of Medicare Part D. The letter requests outreach to providers and clients/consumers who have filled non-formulary drug prescriptions during the transition, so that they will be prepared to switch plans if needed, change medications, or engage the appeals process so that there will be no disruption to service at the end of the transition period.

The letter also requests that CMS require SNPs to outreach to all clients/consumers who have received care and services from out-of-network providers during the transition period and to enroll these providers in networks in order to ensure continuity of care. The letter states that plans may need to provide extensions of the transition period for those who cannot be switched to an in-plan provider within the existing transition period. SNPs must inform clients/consumers of their option to switch plans if there is another plan available with which their provider participates. The letter requests that CMS review the plans’ provider networks for adequacy of access to needed services.

The issue of retrospective authorization of services provided by out-of-network providers during the transition period prior to processing payment also needs attention. This requirement adds an unnecessary step, costs, and delay to the payment process. Secretary Richmond has requested a meeting with CMS to discuss how these issues will be addressed in Pennsylvania. To review the full text of the letter please access this link. Contact Betty Simmonds with questions.

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