Eleven members of Congress have sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure to express their concern over how some Medicare Advantage plans are handling non-invasive ventilator (NIV) claims.
The June 3 letter was sent by Representatives Larry Bucshon (R-Ind.); Ken Calvert (R-Calif.); Jason Crow (D-Colo.); Neal Dunn (R-Fla.); Brian Fitzpatrick (R-Pa.); Raul Grijalva (D-Ariz.); Mike Kelly (R-Pa.); Dan Meuser (R-Pa.); Mariannette J. Miller-Meeks (R-Iowa); Terri A. Sewell (D-Ala.); and Adrian Smith (R-Neb.).
Medicare Advantage plans are denying qualified beneficiaries
“We write today with concern about appropriate patient access to ventilators,” the members of Congress said in their letter. “It has come to our attention that multiple Medicare Advantage (MA) plans and independent review entities are denying patients who qualify for ventilators under National Coverage Determinations (NCDs). We request your attention to this matter, which raises concerns about the enforcement of NCDs by the Centers for Medicare and Medicaid Service in connection with MA plans.”
The letter focuses specifically on non-invasive ventilators for, as the NCD says, “treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. Includes both positive and negative pressure types.”
The representatives said MA plans have created “internal coverage criteria” for NIV coverage, despite Medicare policy says that MA criteria cannot be “more restrictive than fee for service Medicare’s national and local coverage policies.”
Contrary to that policy, “It is our understanding that some MA plans have implemented internal criteria regarding the use of non-invasive ventilators that are more restrictive than the NCD outlines,” the letter said. “Specifically, in some cases MA plans are requiring beneficiaries to undergo additional medical testing, the results of which must satisfy specific metrics not required by fee for service Medicare’s NIV NCD 280.1.
“For example, members of Congress have received outreach from constituents for whom MA plans require that a seriously ill beneficiary with the above covered conditions first try and fail a Respiratory Assist Device (HCPCS EO471), which is not the appropriate treatment for these conditions, before receiving an NIV for which they qualify under the NCD. Moreover, it is concerning that none of these MA plan-promulgated requirements are subject to the stringent NCD rulemaking process. The lack of accountability for the development of internal coverage criteria for MA plans may steer patients into ineffective treatment plans while ignoring widely published evidence establishing the clinical efficacy of NIV.”
[[breakhead]] Qualifying MA plan beneficiaries need equal NIV access
The representatives called on Brooks-LaSure to support equal NIV access for all qualifying Medicare beneficiaries, including those who have chosen MA plan coverage.
“It is clear that action is necessary to ensure the ongoing work of CMS supports all Medicare beneficiaries, individuals with disabilities, and our most at risk patients as intended by the law,” the letter said. “We are requesting guidance from CMS for beneficiaries as well as payors and independent review entities to prevent medically inappropriate denials of care, as well as a review of MA plans’ internal criteria for Medicare beneficiaries suffering from the diseases related to NCD 280.1 for ventilators.”