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Well-known member
Neediest may be hurt by new Medicare drug plan
Victoria Colliver, S.F. Chronicle Staff Writer
Monday, December 12, 2005
Some of the nation's oldest, sickest and poorest people could wind up being
hurt instead of helped by Medicare's new prescription drug benefit, health
advocates warn.
They fear that some people -- including patients in assisted-living homes,
the mentally ill and those with chronic conditions such as AIDS -- could
face higher costs and bureaucratic obstacles that make it harder to get the
drugs they need.
"We're concerned people will abruptly lose access to their drugs," said
Robert Hayes, president of the Medicare Rights Center, one of several
consumer groups that sued to strengthen protections for poor beneficiaries.
On Jan. 1, Medicare, the nation's program for providing health insurance to
seniors and disabled people, for the first time will begin paying part of
the prescription drug costs of millions of Americans. It is the biggest
expansion in the program's 40-year history.
The question of what happens to poor and disabled Medicare beneficiaries is
emerging as a central issue as the new drug benefit gets ready to launch.
In many cases, the extra costs and red tape imposed on the poor are
relatively small. But advocates say they could still be burdensome,
especially for people who are indigent or mentally ill.
The Centers for Medicare and Medicaid Services, the federal agency that
administers Medicare, says it recognizes the potential for disruption and is
installing safeguards to protect vulnerable groups.
"They (health advocates) raise valid concerns and help us anticipate
problems. We're very concerned about (these groups) and are making sure they
transition without any problems," said Jack Cheevers, spokesman in
Medicare's San Francisco office.
For many people, the new drug benefit will provide much-needed help in
paying drug bills. At the same time though, some poor and disabled people
could find that their benefits are reduced or made less accessible by the
new program, consumer groups say.
The people most at risk are so-called dual eligibles -- those who collect
benefits from both Medicare and Medicaid, which is known as Medi-Cal in
California. Medi-Cal is the joint state/federal program that offers health
coverage to poor and disabled Californians.
The two programs complement each other. Medicare provides fairly
comprehensive health coverage, such as hospitalization and doctor visits.
Medi-Cal is needed to pick up costs not covered by Medicare, such as
deductibles, copayments and specialized services. In particular, Medi-Cal
has paid prescription drug costs for poor Medicare beneficiaries.
But that arrangement will be superseded Jan. 1 when more than 1 million
Californians on both Medicare and Medi-Cal will be switched automatically to
new drug plans run by a private companies.
Many dual eligibles could be charged nominal costs for drugs that were
previously free, according to program rules. Others could wind up in drug
plans that don't pay for the medicines they use and find themselves switched
to different drugs.
Another group includes Medicare/Medi-Cal beneficiaries who now get
prescription drug coverage through retiree health plans, such as ones
administered by the California Public Employees' Retirement System. They
could get dropped by their retiree plans and find themselves paying more
under Medicare.
A lawsuit filed last month in a Manhattan federal court by health advocates
seeks to force the U.S. Department of Health and Human Services to
strengthen safeguards for dual eligibles. It warns that the poor and sick
will "fall through the cracks of this massive program transition."
Medicare officials point out that the drug program has both an appeals
process and a transition system to make sure beneficiaries keep getting
needed medications.
The agency "is constantly trying to improve the program," said Mary Ann
Grandlich, a drug benefit expert in Medicare's San Francisco offices. "It's
a new program. We keep discussing things and sometimes we can help."
In at least a few cases, the effects of the Medicare drug benefit could be
near catastrophic. That might be the situation, for example, for some people
with AIDS or HIV.
San Francisco resident Kerry Walters, 51, who has survived AIDS for 16
years, finds himself in a Kafkaesque situation.
Walters, who has been disabled by the disease since 1994, has had a portion
of his medications covered by the AIDS Drugs Assistance Program, a combined
federal/state initiative. He used money the program spent to buy his drugs
to meet his shared-costs responsibility under Medi-Cal.
Now though, under federal law, the AIDS drugs program can't pay those
expenses once the Medicare drug program begins. Walters has calculated that
he will have to pay $459 a month out of his own pocket using the $1,079 a
month he collects from Social Security.
"I am terrified," Walters said. "Nobody seems to be aware that a tectonic
shift in cost sharing is about to occur. The clock is ticking. We have less
than (a few) weeks and it's going to be real."
Most of the nation's more than 40 million Medicare beneficiaries have until
May 15 to sign up for a drug plan without incurring financial penalties.
The 6.4 million Americans on both Medicare and Medicaid are a distinct group
with special needs that might not have been anticipated when the drug
benefit was created.
Many of these dual eligibles take eight to 10 drugs a day for chronic
conditions and need uninterrupted coverage. About 25 percent are in nursing
homes. About 40 percent have cognitive or mental impairments, according to
the National Senior Citizens Law Center. And about 20 percent speak limited
English.
In establishing drug program rules and procedures, Medicare officials have
created a variety of protections for dual eligibles.
For example, dual eligibles won't have to select a drug plan and won't have
to pay premiums. Starting Jan. 1, they will be automatically enrolled in a
free plan. California will have 10 such plans.
In addition, while most Medicare beneficiaries will be allowed to switch
plans only once a year, dual eligibles can do so every month.
To protect those with serious chronic conditions, the federal government
requires plans to cover virtually all drugs in six categories, including
medications for HIV/AIDS, cancer and psychotic conditions. And, dual
eligibles will be required to lay out only nominal copayments of $1 to $3
per prescription.
But some health advocates insist those safeguards aren't enough.
"Where people with HIV were assured the cost of their drugs would be
covered, some of them now face a set of out-of-pocket expenses they did not
previously have," said Dana van Gorder, director of state and local affairs
for the San Francisco AIDS Foundation.
Dual eligibles were sent letters early last month telling them about their
new drug plan, but advocates fear the letter will not reach some people or
that many will not read or understand it. Advocates also warn that patients
could be randomly assigned to plans that don't cover all their medications.
Plans could also force beneficiaries to switch medications, which could
create problems for some patients. And even small copayments could keep poor
people from filling their prescriptions, especially if they take multiple
drugs.
Advocates say that mental health patients are particularly at risk of being
deterred by the drug benefit's red tape.
"Every little hurdle you add to getting medications, you increase the
possibility a person would not be compliant," said Walnut Creek resident
Karen Cohen, the mother of an adult dual-eligible daughter with bi-polar
disorder and a member of the National Alliance for the Mentally Ill.
Dual-eligible beneficiaries who are residents of nursing homes generally
will not have to make copayments for drugs. But those who live in
board-and-care or assisted-living facilities could be required to pay a
portion of the cost of their drugs.
Medicare officials stress that they are fine-tuning the drug program on a
daily basis as they become aware of problems.
For example, Medicare chief Dr. Mark McClellan said last week the government
has contracted with two companies to intervene when dual-eligible patients
aren't properly enrolled.
Pharmacists filling prescriptions for dual eligibles can charge the cost of
a patient's drugs to health insurance giant WellPoint. A second company,
Z-Tech Corp., a Maryland consulting firm, will follow up to ensure that a
beneficiary is assigned to a plan.
"They'll be able to leave the pharmacy with their medications in hand, even
if there's no immediate evidence of what plan they're in," McClellan said.
People on Medicare and Medicaid
About 6.4 million Americans, including more than 1 million Californians,
rely on both Medicare and Medicaid to pay their medical expenses. Starting
Jan. 1, this group will no longer receive drug coverage through Medicaid, a
state/federal program for the poor and disabled that's known as Medi-Cal in
California. Instead, they will automatically be enrolled in privately-run
Medicare prescription drug plans.
Here are some facts about people who are on both Medicare and Medicaid:
-- Nearly 25 percent live in long-term care facilities.
-- Some 70 percent are unable to properly perform one or more tasks of daily
living, such as walking.
-- Most take multiple prescriptions, as many as 10 or more.
-- Almost 40 percent have mental or cognitive impairments.
Source: National Senior Citizens Law Center
Victoria Colliver, S.F. Chronicle Staff Writer
Monday, December 12, 2005
Some of the nation's oldest, sickest and poorest people could wind up being
hurt instead of helped by Medicare's new prescription drug benefit, health
advocates warn.
They fear that some people -- including patients in assisted-living homes,
the mentally ill and those with chronic conditions such as AIDS -- could
face higher costs and bureaucratic obstacles that make it harder to get the
drugs they need.
"We're concerned people will abruptly lose access to their drugs," said
Robert Hayes, president of the Medicare Rights Center, one of several
consumer groups that sued to strengthen protections for poor beneficiaries.
On Jan. 1, Medicare, the nation's program for providing health insurance to
seniors and disabled people, for the first time will begin paying part of
the prescription drug costs of millions of Americans. It is the biggest
expansion in the program's 40-year history.
The question of what happens to poor and disabled Medicare beneficiaries is
emerging as a central issue as the new drug benefit gets ready to launch.
In many cases, the extra costs and red tape imposed on the poor are
relatively small. But advocates say they could still be burdensome,
especially for people who are indigent or mentally ill.
The Centers for Medicare and Medicaid Services, the federal agency that
administers Medicare, says it recognizes the potential for disruption and is
installing safeguards to protect vulnerable groups.
"They (health advocates) raise valid concerns and help us anticipate
problems. We're very concerned about (these groups) and are making sure they
transition without any problems," said Jack Cheevers, spokesman in
Medicare's San Francisco office.
For many people, the new drug benefit will provide much-needed help in
paying drug bills. At the same time though, some poor and disabled people
could find that their benefits are reduced or made less accessible by the
new program, consumer groups say.
The people most at risk are so-called dual eligibles -- those who collect
benefits from both Medicare and Medicaid, which is known as Medi-Cal in
California. Medi-Cal is the joint state/federal program that offers health
coverage to poor and disabled Californians.
The two programs complement each other. Medicare provides fairly
comprehensive health coverage, such as hospitalization and doctor visits.
Medi-Cal is needed to pick up costs not covered by Medicare, such as
deductibles, copayments and specialized services. In particular, Medi-Cal
has paid prescription drug costs for poor Medicare beneficiaries.
But that arrangement will be superseded Jan. 1 when more than 1 million
Californians on both Medicare and Medi-Cal will be switched automatically to
new drug plans run by a private companies.
Many dual eligibles could be charged nominal costs for drugs that were
previously free, according to program rules. Others could wind up in drug
plans that don't pay for the medicines they use and find themselves switched
to different drugs.
Another group includes Medicare/Medi-Cal beneficiaries who now get
prescription drug coverage through retiree health plans, such as ones
administered by the California Public Employees' Retirement System. They
could get dropped by their retiree plans and find themselves paying more
under Medicare.
A lawsuit filed last month in a Manhattan federal court by health advocates
seeks to force the U.S. Department of Health and Human Services to
strengthen safeguards for dual eligibles. It warns that the poor and sick
will "fall through the cracks of this massive program transition."
Medicare officials point out that the drug program has both an appeals
process and a transition system to make sure beneficiaries keep getting
needed medications.
The agency "is constantly trying to improve the program," said Mary Ann
Grandlich, a drug benefit expert in Medicare's San Francisco offices. "It's
a new program. We keep discussing things and sometimes we can help."
In at least a few cases, the effects of the Medicare drug benefit could be
near catastrophic. That might be the situation, for example, for some people
with AIDS or HIV.
San Francisco resident Kerry Walters, 51, who has survived AIDS for 16
years, finds himself in a Kafkaesque situation.
Walters, who has been disabled by the disease since 1994, has had a portion
of his medications covered by the AIDS Drugs Assistance Program, a combined
federal/state initiative. He used money the program spent to buy his drugs
to meet his shared-costs responsibility under Medi-Cal.
Now though, under federal law, the AIDS drugs program can't pay those
expenses once the Medicare drug program begins. Walters has calculated that
he will have to pay $459 a month out of his own pocket using the $1,079 a
month he collects from Social Security.
"I am terrified," Walters said. "Nobody seems to be aware that a tectonic
shift in cost sharing is about to occur. The clock is ticking. We have less
than (a few) weeks and it's going to be real."
Most of the nation's more than 40 million Medicare beneficiaries have until
May 15 to sign up for a drug plan without incurring financial penalties.
The 6.4 million Americans on both Medicare and Medicaid are a distinct group
with special needs that might not have been anticipated when the drug
benefit was created.
Many of these dual eligibles take eight to 10 drugs a day for chronic
conditions and need uninterrupted coverage. About 25 percent are in nursing
homes. About 40 percent have cognitive or mental impairments, according to
the National Senior Citizens Law Center. And about 20 percent speak limited
English.
In establishing drug program rules and procedures, Medicare officials have
created a variety of protections for dual eligibles.
For example, dual eligibles won't have to select a drug plan and won't have
to pay premiums. Starting Jan. 1, they will be automatically enrolled in a
free plan. California will have 10 such plans.
In addition, while most Medicare beneficiaries will be allowed to switch
plans only once a year, dual eligibles can do so every month.
To protect those with serious chronic conditions, the federal government
requires plans to cover virtually all drugs in six categories, including
medications for HIV/AIDS, cancer and psychotic conditions. And, dual
eligibles will be required to lay out only nominal copayments of $1 to $3
per prescription.
But some health advocates insist those safeguards aren't enough.
"Where people with HIV were assured the cost of their drugs would be
covered, some of them now face a set of out-of-pocket expenses they did not
previously have," said Dana van Gorder, director of state and local affairs
for the San Francisco AIDS Foundation.
Dual eligibles were sent letters early last month telling them about their
new drug plan, but advocates fear the letter will not reach some people or
that many will not read or understand it. Advocates also warn that patients
could be randomly assigned to plans that don't cover all their medications.
Plans could also force beneficiaries to switch medications, which could
create problems for some patients. And even small copayments could keep poor
people from filling their prescriptions, especially if they take multiple
drugs.
Advocates say that mental health patients are particularly at risk of being
deterred by the drug benefit's red tape.
"Every little hurdle you add to getting medications, you increase the
possibility a person would not be compliant," said Walnut Creek resident
Karen Cohen, the mother of an adult dual-eligible daughter with bi-polar
disorder and a member of the National Alliance for the Mentally Ill.
Dual-eligible beneficiaries who are residents of nursing homes generally
will not have to make copayments for drugs. But those who live in
board-and-care or assisted-living facilities could be required to pay a
portion of the cost of their drugs.
Medicare officials stress that they are fine-tuning the drug program on a
daily basis as they become aware of problems.
For example, Medicare chief Dr. Mark McClellan said last week the government
has contracted with two companies to intervene when dual-eligible patients
aren't properly enrolled.
Pharmacists filling prescriptions for dual eligibles can charge the cost of
a patient's drugs to health insurance giant WellPoint. A second company,
Z-Tech Corp., a Maryland consulting firm, will follow up to ensure that a
beneficiary is assigned to a plan.
"They'll be able to leave the pharmacy with their medications in hand, even
if there's no immediate evidence of what plan they're in," McClellan said.
People on Medicare and Medicaid
About 6.4 million Americans, including more than 1 million Californians,
rely on both Medicare and Medicaid to pay their medical expenses. Starting
Jan. 1, this group will no longer receive drug coverage through Medicaid, a
state/federal program for the poor and disabled that's known as Medi-Cal in
California. Instead, they will automatically be enrolled in privately-run
Medicare prescription drug plans.
Here are some facts about people who are on both Medicare and Medicaid:
-- Nearly 25 percent live in long-term care facilities.
-- Some 70 percent are unable to properly perform one or more tasks of daily
living, such as walking.
-- Most take multiple prescriptions, as many as 10 or more.
-- Almost 40 percent have mental or cognitive impairments.
Source: National Senior Citizens Law Center
