Fact Sheets

PART D RECONSIDERATION APPEALS DATA

Part D Appeals Process

An appeal is the process by which an individual enrolled in a Medicare prescription drug plan (an “enrollee”) may challenge a plan’s coverage determination.  Appeals begin with a request by a beneficiary (or their representative) for a redetermination by the plan.  If the redetermination response by the plan is not satisfactory for the beneficiary, the beneficiary may request a reconsideration by the Part D independent review entity (also called the Part D qualified independent contractor or “QIC”).  Beneficiaries may subsequently appeal the independent review decision to an administrative law judge, the Medicare Appeals Council, and federal judicial review.

 

The following data summarizes and highlights some of the key data on reconsiderations since the inception of the Medicare prescription drug benefit program on January 1, 2006. 

 

Reconsideration Volume

8,772 reconsideration requests were received from January 1, 2006 through July 31, 2006. [1]   This represents a rate of 0.44 reconsiderations for each 1000 Medicare beneficiaries enrolled.[2]

 

Standard cases represented 90% of all appeals received and resulted in a rate of 0.40 standard cases for each 1000 beneficiaries enrolled.

 

Expedited cases represented 10% of all appeals received and resulted in a rate of 0.04 expedited cases for each 1000 beneficiaries enrolled.

 

Number of appeals received by the Part D QIC by month:

 

Rate of appeals received by the Part D QIC by month:[3]

 

 

Types of Appeals

Of the 8,336 appeals decided through July 31, 2006:

36 percent involved a drug utilization management tool dispute and represents 0.15 drug utilization appeals for each 1000 beneficiaries enrolled.

 

34 percent involved an off-formulary exception request and represents 0.14 off-formulary exceptions appeals for each 1000 beneficiaries enrolled.

 

26 percent involved a non-Part D drug (a drug that is statutorily excluded) request and represents 0.11 non-Part D drug requests for each 1000 beneficiaries enrolled.

 

2 percent involved a cost-sharing dispute and represents 0.01 cost-sharing dispute appeals for each 1000 beneficiaries enrolled.

 

Less than 2 percent involved a tiering exception request and represents 0.01 tiering exceptions appeals for each 1000 beneficiaries enrolled.

 

Less than 1 percent involved out-of-network pharmacy coverage.

 

Overall Reversal Rate

Excluding cases that were dismissed, withdrawn, or remanded (the Part D QIC did not have jurisdiction to make a substantive decision on the case) and cases involving non-Part D drugs, the Part D QIC reversed plan decisions in 42% of cases.[4]

 

Reversal Rates by Appeal Type[5]

Drug utilization management tool dispute 51%

Off-formulary exception request             31%

Non-Part D drug                                               15%

Tiering exception request                                   33%

Cost-sharing dispute                                          33%

Out-of-network pharmacy coverage                   60%

 

Overall Timeliness of Reconsideration Cases

 

Distribution of decided appeals by process days for all reconsideration cases: