Medicare drug plan enrollment ends; appeals begin

May 15 is the deadline for beneficiaries to enroll in one of the new Medicare Part D prescription drug plans for coverage in 2006. Those who haven't joined a plan by that date and don't already have comparable drug coverage will have to wait until the next open enrollment period, Nov. 15 to Dec. 31, 2006, with coverage beginning Jan. 1, 2007. They will also have to pay higher premiums for drug coverage – at least 1 percent more per month for every month they waited to join.

As Medicare patients enroll in these drug plans, many are finding that their current medications are not covered under their plan's formulary. However, according to the Centers for Medicare & Medicaid Services, there is help:

• All drug plans must provide newly enrolled beneficiaries with a transitional supply of non-formulary drugs for a minimum of 30 days. The patient and physician can use the transition period to switch to another suitable drug on the formulary or, if the non-formulary drug is medically necessary, to apply for an exception.

• To request an exception, contact the drug plan. (For contact information, visit http://www.medicare.gov/MPDPF/Shared/Include/Formulary/FormularyFinder.asp; for an exceptions request form, visit http://www.cms.hhs.gov/MLNProducts/Downloads/Form_Exceptions_final.pdf.) The plan is required to reply within 72 hours for standard requests or 24 hours for expedited requests. Exceptions are good for the rest of the plan year.

• If an exception is not granted, contact the plan within 60 days and request an appeal. (See http://www.medicare.gov/Publications/Pubs/pdf/11112.pdf for more details.)

AAFP defends use of high-level E/M codes

The AAFP recently informed health plans across the nation that they should anticipate an increase in the number of high-level evaluation and management (E/M) codes billed by family physicians and should pay for them fairly. Recently, Anthem of Southern Ohio announced it would begin reimbursing codes 99213 and 99214 at a “blended rate.”

In an April 7 letter, AAFP Board Chair Mary Frank, MD, justified the increase in high-level E/M codes, noting that an aging of the population and an increase in chronic disease management result in more complex care being provided by family physicians. In addition, she noted that the use of electronic health records often improves physicians' coding and documentation.

“It is important to the AAFP that all insurers pay physicians for the appropriate level of care that is delivered, documented and coded,” she said.

TransforMED selects 36 practices to test new model of care

An $8 million national demonstration project intended to test the effectiveness of a new model of care, and eventually transform the delivery of health care, has officially begun. TransforMED, the AAFP-established organization leading the project, has selected 36 family medicine groups that will be embarking on a total redesign of their practices.

Selected from a pool of more than 300 applicants, the 36 practices include both large and small groups in a variety of settings. The practices will be implementing a model of care drawn from the Future of Family Medicine project.¹ The model includes innovations such as open-access scheduling, electronic health records, and leveraging and engaging clinical staff.

The practices will be divided into two groups: one group receiving assistance provided by TransforMED and the other group working independently. Both groups will undergo evaluation by independent researchers to assess the model's impact and the most effective way to implement the model.

The project will provide “an objective view into what the TransforMED model looks like in real-world practices, and it will measure the model's effect on practice and patient outcomes,” said Terry McGeeney, MD, MBA, president and CEO of TransforMED. “Perhaps most importantly, the knowledge gained from this project will be used to further more widespread efforts to transform practices with the goal of improving the quality of care for patients.”

Key findings from the project will be disseminated regularly, with a final report due in early 2009.