Academic journal article Care Management Journals

6.4 Million at Risk: Protecting the Poorest Americans during the Medicare Drug Transition

Academic journal article Care Management Journals

6.4 Million at Risk: Protecting the Poorest Americans during the Medicare Drug Transition

Article excerpt

Editor's Note. The following document is reprinted and adapted for the Journal format with permission from the Medicare Rights Center (www.medicarerights.org).

Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), 6.4 million "dual eligibles"-low-income individuals who are enrolled in both Medicare and Medicaid-will lose their Medicaid drug coverage on January 1, 2006. Each dual eligible will be transferred into one of the hundreds of new Medicare "Part D" prescription drug plans for drug coverage. Because Medicaid drug coverage ends on the first day that Medicare drug coverage begins, the transition leaves no margin for computer or human error. As a result, millions of dual eligibles could experience gaps in drug treatment during the first months of Part D. Such gaps could have catastrophic human consequences. The political consequences could include widespread perception of a failed rollout of the Medicare prescription drug benefit. If 95 percent of dual eligibles make a smooth transition in January 2006, more than 300,000 of the frailest Americans will lose access to needed medicine.

Dual eligibles have extensive health care needs, and they are among the most vulnerable men and women in both Medicare and Medicaid. Compared to other Medicare beneficiaries, dual eligibles are far more likely to be sick, from underserved ethnic backgrounds, living in rural areas, lacking high school diplomas, living in nursing homes, and very poor. Nearly a quarter live in institutions, and four in ten have a cognitive impairment.

Transitioning dual eligibles into Part D will happen in a very compressed timeframe (see Figure 1). Most dual eligibles will be notified by mail of their random assignment into a Part D plan in late October. Between then and December 31, 2005, dual eligibles will have to learn how to navigate a complex new program and how to evaluate formularies, access drugs that may not be on plan formularies, and understand pharmacy networks as well as other features of their plans.

In general, Part D drug coverage will differ from Medicaid drug coverage in several important respects, including the specific drugs that are covered, the pharmacies that enrollees may use, copayment rules, and the availability of emergency supplies pending appeals when a plan denies coverage of a prescribed medication.

While the Centers for Medicare and Medicaid Services (CMS) has taken important steps to improve automatic enrollment processes and formulary protections, the final transition process remains inadequate to ensure a smooth transition for dual eligibles. Dual eligibles face serious risks, including falling through the cracks of complicated data exchanges between and among the Social Security Administration (SSA), CMS, plans and states; losing coverage because of formulary and pharmacy network limitations; and not understanding changes in their coverage enough to navigate the complicated new system. All patients face risks that their doctors and pharmacists will be overwhelmed by the demands of the new system in the early months of the new Part D benefit.

Congress could reduce the risks of a precarious transition strategy by extending the availability of Medicaid as backup drug coverage during a reasonable transition period to Part D. With a safety net in place, CMS, states, health advocates, drug plans and providers would have time to implement a comprehensive education and transition plan that would ensure that all dual eligibles are successfully enrolled in Part D plans; that they know how and where they can obtain necessary drugs; and that their doctors have had adequate time and information to review and, if necessary, appeal new formulary guidelines.

OVERVIEW

Under the MMA, 6.4 million "dual eligibles" (low-income individuals enrolled in both Medicare and Medicaid) will lose their Medicaid drug coverage on January 1, 2006. Each dual eligible will be transferred into one of the hundreds of new Medicare "Part D" prescription drug plans for drug coverage. …

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