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Denials and Appeals in Medicare Part D

CMS uses a capitated payment model to pay private insurers that provide and administer Medicare Part D benefits. Capitated payment models are on a payment-per-person rather than a payment-per-service basis, and they can create an incentive to deny access to services or payment in order to increase an insurer's profits. Beneficiaries can appeal denied prescriptions and payments to multiple levels of review within the administrative appeals process. We will examine national trends and CMS's oversight of prescription drug denials in Part D during 2014-2016. We will determine the extent to which denials that have been appealed to each level of review were overturned. We will also examine variations in appeals and overturned denials across Part D contracts and evaluate CMS's efforts to monitor and address inappropriate denials in Part D.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
June 2019 Centers for Medicare & Medicaid Services Denials and Appeals in Medicare Part D Office of Evaluation and Inspections OEI-09-16-00411 2020