ACA: CMS needs our help!

On January 1, 2014, benefits will kick in for more than 1.1 million Americans who have thus far signed up for health coverage through the Affordable Care Act’s (ACA) federal health insurance marketplaces. CMS gratefully recognizes the helping hand lent by pharmacists during the Medicare Part D rollout in 2006, and is once again seeking our assistance. Now, as we approach this milestone in the implementation of the ACA, the agency is asking us to help identify systemic problems that pharmacists are experiencing when processing the claims of these newly insured individuals.

Following a recent meeting of pharmacy representatives at the White House and a December 23 CMS conference call, Twlug and our colleague pharmacy associations are reaching out to pharmacists to aid CMS in collecting feedback on systemic problems associated with the ACA marketplaces. CMS believes that pharmacists are well positioned to detect issues earlier than other health professionals because they adjudicate claims in real-time.

Twlug has set up a dedicated e-mail address at [email protected] to collect issues and problems on behalf of CMS. The following are some examples of the categories of problems that may be reported:

  1. Drug not covered (e.g., common generic drugs or brand-name drugs that have no generic equivalent or alternative)
  2. Plan limits exceeded (e.g., common days of supply not for maintenance medications being rejected)
  3. Failure to issue patients’ insurance cards
  4. Formulary does not span all disease states
  5. Prior authorization needed for every claim
  6. Nonmatched patient ID or birthdate for the cardholder or the cardholder’s family members when information they present to you is entered and billed properly

Please include any information that helps identify the actual insurer. If the patient presents an insurance card that doesn’t readily reveal the insurer’s identity, please provide as much information as you can off the card without divulging any protected health information. Such insurer-related information includes group number, Rx group number, BIN and PCN number.

It’s important to note that for help in resolving these issues, CMS has established a toll-free phone number that beneficiaries can call to convey any individual problems with ACA insurance at 800-318-2596.

Happy new year, everyone!