OIG investigates Medicare Part D coverage for dual eligibles

June 9, 2008

A study from the Office of the Inspector General of the department of Health & Human Services finds problems for dual-eligible residents of nursing facilities with Medicare Part D.

In two separate reports the Office of the Inspector General of the Department of Health & Human Services questioned the coverage of dual-eligible residents in nursing facilities. In a study of the availability of Medicare Part D drug plans, OIG found that most dual-eligible nursing home residents received the drugs they needed, but that nursing homes and long-term care pharmacies sometimes end up paying for drugs that are not covered by the patient's plan. Administrators and pharmacy directors explained to OIG that the drugs either are not on the residents? Part D plan formularies or require prior authorization. OIG recommended that CMS work with plans to ensure that formularies meet the needs of dual-eligible nursing home residents and work with plans to improve the prior authorization process, and encourage long-term care pharmacies to disclose to physicians information about rebates that they receive from drug manufacturers. In a second study on the role facilities play in assisting dual-eligibles with selecting Part D plans, OIG found that some facilities may be violating CMS' rules prohibiting nursing homes from coaching or steering residents to select plans.

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