Medicare and Part D

The New Prescription Drug Benefit:
Medicare Part D

January 1, 2006 marked the largest change in public benefits in 40 years. Medicare added prescription drug coverage, Medicare Part D, to its benefit package. Medicare is the insurance program that covers seniors and previously working people who are disabled. Until 2006, Medicare had no prescription drug coverage.

Medicare covers 60,000 to 80,000 people with HIV/AIDS nationwide. Between 70% and 85% of those are eligible for both Medicare and Medicaid (the healthcare program for low-income people who fall into certain categories, including disability). People who have both Medicare and Medicare are considered dual eligibles.

If you have Medicare coverage only or if you are dually eligible, it is important that you understand the benefit and how to navigate it. For more information on the benefit itself, see www.projectinform.org.

Unfortunately, getting all the information and assistance you may need to sign up with and navigate the new private prescription drug plans is no small feat. In addition to being complex and difficult to access, the program is off to a rough start. The beginning of implementation has been plagued with problems that have presented significant barriers to care.

On January 1, 2006, more than 6 million dual eligibles lost comprehensive Medicaid coverage and were automatically enrolled in Part D private drug plans. Many of the remaining Medicare beneficiaries have until May 15, 2006 to sign up for a plan before they suffer a penalty of a higher premium for their plan.

This article will focus on dual eligibles because they are the most vulnerable (sickest and poorest) beneficiaries, among the first to enter the benefit, and most states have reported significant problems with access to drugs for this group. Some estimate that as many as 20% have been unable to access essential medications they require under Medicare Part D.

Dual eligibles and many others faced multiple problems in the first month of implementation of Medicare Part D. Many didn’t receive or didn’t understand information regarding their new Medicare benefit. Dual eligibles were automatically assigned at random to specific plans; however, when people went to pick up their drugs, many didn’t know what plan they had been assigned to. Neither the Centers for Medicaid and Medicare Services (CMS), the agency that oversees both Medicare and Medicaid, nor the private plans that distribute the drugs had enough customer support to deal with the overwhelming number of problems. Beneficiaries, their providers, and pharmacists spent hours on hold for CMS and plan representatives often only to get no information, misinformation, or further delays. Many left the pharmacy without critical drugs. We spoke to several who had been without anti-HIV drugs, anti-psychotics, anti-depressants, and other essential drugs for periods of time from several days to several weeks.

Of those who did receive information, many were assigned to plans that didn’t meet their needs and, after researching other options, found a better plan. Changing plans, however, also resulted in problems. Many didn’t show as enrolled in their new plans—or in their old plans. Pharmacies were reluctant to give out drugs, not knowing how they would get reimbursed, but also couldn’t get through to plans or CMS to solve the problems. Often if they did get through to someone, the person couldn’t solve the problem. When people changed plans, there was a time lag in applying the extra help Medicare gives to low income people, and almost all dual eligibles, to help pay for drugs. People with very low incomes were being asked for hundreds of dollars to pick up their drugs. Again, many left pharmacies without drugs.

Plans were supposed to cover all or substantially all of six classes of drugs, including anti-HIV, anti-depressant, anti-psychotic, anti-convulsant, anti-cancer, and immunosuppressant drugs. In addition, plans were not allowed to require prior authorization, step therapy, dosage limitation or other types of “management” tools for anti-HIV drugs. But some plans didn’t think they were covering some of these drugs or they required some interaction with the provider before people could get their anti-HIV drugs.

All plans were supposed to offer a transition plan for those who were stabilized on a treatment regimen. The plans were to continue coverage of the current drugs for a minimum amount of time while the plan looked at its formulary and the beneficiary’s need. Many of the plans didn’t appear to be honoring transition periods but perhaps the larger problem is beneficiaries aren’t aware of their rights to transition coverage and no one, including providers, understood how to invoke it.

The problems were severe enough that thirty-seven states declared some type of emergency coverage for dual eligibles who have had problems accessing their drugs. CMS has now promised that it will help states with reimbursement for the coverage they have been providing.

Although these problems are related to implementation and CMS is working with the plans and states to solve systemic problems, as well as with advocates and others to solve individual problems, some of the issues are unlikely to go away. California alone has approximately 10,000 people who qualify for Medicare as dual eligibles each month. There is little indication that effective systems are in place to deal with this ongoing transition without a serious gap in prescription drug coverage. Also, although the numbers of problems should decrease going into the future, even smaller numbers of people unable to access essential medication still results in serious individual psychological and physical health risks as well as increased health care costs.

In addition to the transition problems, there is a serious set of problems associated with the benefit that will continue even if all eligibility and transition problems are solved. These include a significant cost burden for many, if not most, beneficiaries. Because the plans are private plans, protections for beneficiaries are inadequate. The stand alone prescription drug plans serving most beneficiaries have almost unlimited control over formularies with little direct incentive to provide more comprehensive or affordable coverage because they are not responsible for the primary and emergency care beneficiaries will need if they become destabilized on their treatment regimens.

In addition, traditional private plans are not set up to serve most dual eligibles. This population, in addition to being the sickest and poorest population, suffers from a disproportionate amount of physical, cognitive, and mental health challenges, making continuity of care essential and navigation of complex health systems extremely difficult. Many of the providers serving dual eligibles are working in clinic settings where resources may be more limited than private practices and there are not enough community advocates and benefits specialists to adequately assist people with the challenges of accessing care and navigating private health plans.

Both the short term and long term problems may leave many beneficiaries unable to access medications, confused as to how to engage with their coverage and create many issues for advocates to work on at both state and federal levels. There are several bills pending in Congress to address some of the limitations of Medicare Part D. If you want to receive information on these bills, go to www.projectinform.org. We will send members information on viable Medicare Part D legislation.

Tips on Medicare Part D:
In spite of problems with this benefit, enrolling in a Medicare drug plan will be the best or only way for most HIV-positive Medicaid beneficiaries to get prescription drugs. It remains important that individuals, advocates, government agencies and elected officials work together to make the benefit work as well as possible. If you are having trouble getting your medications, there are several things you can do:

• Your state may be offering emergency Medicaid coverage. Ask your pharmacist if you qualify.

• Be sure you always have your Medicaid and Medicare card (when available) with you when you go to pick up drugs.

• If you are being asked to pay more than you should because you receive extra help, ask your pharmacist to solve the problem directly with the plan. If he or she can’t do that ask them to solve it with CMS. If still not solved, ask if your state Medicaid can pick up the extra co-pay until the problem is solved. Don’t leave the pharmacy without your drugs.

• If you are successfully enrolled in a plan but can’t get a specific medication, remind the pharmacist that every plan is supposed to give a “transition fill” or at least 30 days of any medications you are currently taking. CMS has extended the time for longer transition fills until March 31st, 2006. For more information click on www.projectinform.org.

• Once you get your transition fill, be certain to work with your doctor and plan to ensure that all the drugs you need are on your plan or that you request an exception for the drug you need. Check www.medicareadvocacy.org for instructions on how to file exceptions and appeals. If you have trouble accessing your transition fill, report the problem to CMS as instructed above.

• If you find yourself in a plan that doesn’t work for you, consider changing your plan. If you don’t fully understand the plans or the benefit, look for an advocate, case manager, benefits counselor or someone who can assist you with plan selection. If you have Medicare coverage only, without Medicaid, be careful in your plan selection. Once you have made a selection, generally you are locked in for a year. During the initial implementation period, you should have one chance before May 15, 2006 to make a change. If you are dual eligible, you may change plans as frequently as you need, however, you are limited to the “zero premium” plans or those that CMS pays for fully unless you can afford to pay more each month.

• 1-800-Medicare has been set up as assistance to beneficiaries. Unfortunately, many have reported problems using the assistance line, including misinformation, long waits and inaccurate referrals. Others have reported success with information. The long wait times seem to have improved significantly and the accuracy of information should improve also. You can also seek assistance from your pharmacist, medical provider, friends and advocates.

• Remember: Report any problems you have directly to CMS and cc advocates. Check www.projectinform.org for reporting instructions. CMS has been working to solve individual problems and advocates need your information and story to make positive changes. You may also report the problem anonymously.

• Remember to write or e-mail your Senators and Representative in Congress and describe the challenges you face. The only way to make changes in this benefit is to let your elected officials know about your experiences.

For contact information for your elected officials, go to www.congress.org.