NACDS Urges Assistance for New Exchange Beneficiaries

SEPTEMBER 07, 2014
Arlington, Va. – The National Association of Chain Drug Stores (NACDS) has written to the Centers for Medicare & Medicaid Services (CMS) to “recommend 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 CMS Administrator Marilyn Tavenner.

NACDS detailed the technical rationale for each of its recommendations, with a focus on optimizing the experience of patients during this next transition phase for millions of Americans:
  • “First, as to the call centers, there were concerns in 2014 that some of the state run call centers might not have been open on holidays, such as Christmas Day and New Year’s Day. To meet beneficiary needs, we believe that all call centers should be open throughout the holiday season, especially New Year’s Day. 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.”
  • “Second, as in 2014, we remain concerned that 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. 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.”
  • “Finally, at the start of a plan year, there often can be confusion concerning coverage for specific medications for new plan enrollees. Difficulties in adjudicating such drug claims can lead to 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. 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’ recommendations reflect its engagement in late 2013, when the Association advised the agency of steps necessary to improve the January 1, 2014, roll-out of exchange-based insurance coverage as a result of the Affordable Care Act (ACA).

In 2013, NACDS conducted extensive outreach with members to help identify and solve potential difficulties related to the exchange roll-out, and to maintain open communication throughout its implementation. NACDS also participated in regular White House meetings and conference calls as the calendar turned from 2013 to 2014, and was invited to a White House event in May 2014 with President Obama and the First Lady to thank those who worked to smooth the experience of patients during the transition.

NACDS has likened pharmacy’s ACA implementation to pharmacy’s education efforts during the 2006 rollout of Medicare Part D, the response to H1N1, a consistent and concerted national flu vaccination campaign, and the providing of necessary goods and services during national crisis situations.

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