Medicare Drug Benefit
Goes Live: Tips to Ensure Smooth Transition
More than two years after Congress passed legislation authorizing a
new prescription drug benefit in Medicare, the program went into effect
on Sunday, January 1, 2006. Still, there are concerns about how the
initial period of transition to the new benefit will work. For more
than 18 months, the federal government and the private drug plans that
will be administering the new program have been working to ensure that
coverage is seamless. Despite all the planning, however, problems are
expected during the initial roll-out, given that 21 million seniors
and people with disabilities will be covered by the program from its
outset.
A Few Tips and Reminders
There should be no gap in coverage for individuals who are
dually eligible for both Medicare and Medicaid (see details below);
Make sure to bring any enrollment information you have been sent by
Medicare to your local pharmacy when filling a prescription (if you
have not been sent enrollment information, bring your Medicare enrollment
number with you);
Retail pharmacists are required to have computer software that can instantaneously
verify eligibility and plan enrollment;
Medicare beneficiaries who are not dually eligible for both Medicare
and Medicaid will not be automatically signed up for the drug benefit;
for these beneficiaries, enrollment is optional. Help with enrollment
and plan selection is available 24-7 through 1/800-MEDICARE and www.medicare.gov
Even though the benefit began on January 1, the "open enrollment"
period runs through May 15, 2006 (allowing Medicare beneficiaries to
enroll in a plan with no penalty);
Transition for Dual
Eligibles
Of particular concern are the 6.3 million Medicare beneficiaries who
are also eligible for Medicaid — the so-called dual eligibles.
For these individuals, participation in the new Medicare drug benefit
is mandatory; coverage of prescriptions under their state Medicaid programs
ended on December 31, 2005.
To ensure seamless coverage, dual eligibles have been automatically
enrolled in a new Medicare drug plan and that plan must offer immediate
coverage. Most dual eligibles received an auto-enrollment notice from
Medicare in November. Dual eligibles are strongly encouraged to hold
on to this letter and bring it with them to their pharmacist with their
first round of prescriptions in 2006. However, even without the letter
from Medicare, all retail pharmacists are supposed to be able to instantly
verify plan enrollment. In other words, while the enrollment letter
or enrollment card can be helpful, what really matters is electronic
verification at the pharmacy counter.
Obligations of the
Medicare Drug Plans Serving Dual Eligibles
The Medicare drug plans that dual eligibles have been enrolled in are
required to meet the following standards:
They must offer drug coverage to dual eligibles at no monthly premium,
no annual deducible, and no gap in coverage;
They can NOT impose cost sharing on dual eligibles that exceeds $1 for
a generic drug, or $3 for a brand-name drug (cost sharing is waived
for dual eligibles in nursing homes, acute care hospitals and some other
institutional settings);
They must cover all the drugs prescribed for a dual eligible prior to
January 1 (i.e., if a dual eligible was prescribed a medication prior
to January 1, it must be immediately covered);
They must cover "all or substantially all" of the medications
commonly prescribed to treat mental illness, including "all or
substantially all" anti-psychotics, anti-depressants; and anti-convulsants;
They can NOT cover medications known as benzodiazepines (e.g., Klonopin,
Ativan, Xanax), although nearly every state Medicaid program has elected
to cover these medications for dual eligibles;
They must allow a dual eligible to switch to a different drug plan at
any time (so long as the plan's cost is at or below the average "benchmark"
plan in the region; and
They must respond quickly (within 72 hours) for a request from a beneficiary
and their doctor for an exception to any restriction in their coverage
(e.g., to cover a medication that is not on the plan's preferred drug
list or to waive a prior authorization requirement).
A few last minute
concerns on the transition for dual eligible beneficiaries:
What happens to dual eligibles who have not been auto-enrolled or have
not been notified of auto-enrollment prior to January 1?
No government program has ever transitioned 6.3 million people without
a mistake, and the new Medicare drug program is unlikely to be an exception.
Some dual eligibles have not been auto-enrolled (due to the discrepancies
between state and federal lists) or have not received enrollment notices
(inaccurate mailing addresses, clerical errors, etc.). To deal with
such cases, the Centers for Medicare and Medicaid Services (CMS ? the
federal agency that administers Medicare) has set up a "Point of
Sale" system that will allow a dual eligible to immediately get
prescriptions filled and initiate immediate auto-enrollment.
How will the "Point of Sale" System Operate?
A dual eligible presents proof of eligibility in both programs. This
can be their Medicare enrollment number and any proof that they are
Medicaid eligible (Medicaid card, letter from Social Security declaring
SSI eligibility, even asking the pharmacist to check on the computer
to see that Medicaid paid for a prescription prior to January 1). Once
the beneficiary demonstrates proof of eligibility for both programs,
the pharmacy is required to fill the prescription and charge only $1
for a generic drug and $3 for a brand name drug. The pharmacist is also
required to initiate enrollment by alerting a national vendor, who will
verify the individual's dual eligibility status and auto-enroll them
in a national plan. All of this is designed to take place at the pharmacy
counter so that the dual eligible is able to get the prescriptions filled
immediately and ensure rapid enrollment in a Medicare drug plan.
Are pharmacies required to
collect the $1/$3 cost sharing from dual eligible beneficiaries?
Sort of. The law appears to require that dual eligibles meet their cost
sharing obligations ($1 for a generic drug, $3 for a brand name drug). However,
the regulations specifically mention that a retail pharmacist can, at
their discretion, waive cost sharing for a dual eligible. However,
a retail pharmacist cannot establish a blanket policy to waive cost
sharing for all dual eligibles, nor can they advertise their willingness
to forgo cost sharing for dual eligibles. As a result, some pharmacies
may be reluctant to waive cost sharing. At the same time, nothing prevents
a pharmacist from allowing a third party including a family member or
friend from making co-payments on the dual eligible's behalf.
Are all pharmacies participating in the new Medicare drug benefit?
Yes. However, not every pharmacy whether a chain drug store or an independent
retailer is part of every drug plan's pharmacy network. The law
requires every Medicare drug plan to have an adequate pharmacy network
based on geographic proximity to plan enrollees (including dual eligibles).
Drug plans are also required to disclose to enrollees the pharmacies
that are in their network. Dual eligibles can switch drug plans at any
time if they wish to move to a plan that includes a specific pharmacy.
Will Medicare beneficiaries who reside in group homes, supportive housing
programs or other congregate settings that offer on-site pharmacies
(or have agreements with a pharmacy) be able to continue to get their
medications as before?
In some cases, yes. As noted above, every drug plan will have its own
pharmacy network. Unfortunately, this does not mean that most Medicare
drug plans have established contracts or relationships with in-house
pharmacies in group homes, board and care homes, supportive housing,
etc. It is critically important for community health centers, mental
health agencies and nonprofits that manage supportive housing programs
to know which plans their dual eligible tenants have been enrolled in
and to reach out to these plans and insist that their pharmacies be
included in each drug plan's network.
CMS has provided guidance
to every Medicare drug plan encouraging them to do this. There is no
legal or regulatory barrier preventing in-house pharmacies from continuing
to provide medications to their residents who are dual eligible beneficiaries.
It just requires them to deal with a new entity (a Medicare drug plan),
as opposed to Medicaid or the state health authorities. Some consumer
organizations are especially concerned that Medicare drug plans have
not done the work necessary to ensure that systems that have traditionally
worked to provide medications to dual eligibles who have disabilities
can continue to do so under the drug benefit. This may be further complicated
by difficulties that case managers and other treatment professionals
have been experiencing in finding out which plans the consumers they
serve have been enrolled in.
Are there other
web-based resources with information on Medicare Part D enrollment?
Yes
www.medicare.gov
www.medicarepartd.org
www.maprx.info
www.cms.hhs.gov/partnerships/downloads/whatif1.pdf
www.cms.hhs.gov/center/partner.asp
Source: NAMI (National Alliance on Mental Illness), a not-for-profit,
grassroots, self-help, support and advocacy organization. www.nami.org
