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Medicare Drug Benefit Update: 

Consumer and Family Tip Sheet Available to Help Dual Eligibles Address Coverage Problems; Bills Introduced in Congress to Address Gaps

February 15, 2006

The Medicare Part D drug benefit is now 45 days old and while many of the problems that plagued the early days of the benefit have been addressed, some problems persist.  Of particular concern to NAMI are coverage gaps faced by low-income beneficiaries with severe mental illness who are concurrently (dually) eligible for both Medicare and Medicaid. 

More than 22 states are currently using Medicaid to cover medications for dual eligibles.  But since the beginning of February, a number of states have suspended temporary coverage for dual eligibles in order to press pharmacies to first seek payment from Medicare drug plans and only use state Medicaid as a payor of last resort.  As noted in an E-News last week, the Centers for Medicare and Medicaid Services (CMS) extended transition guidance that requires Medicare drug plans to cover all medications prescribed to dual eligibles through at least March 31, 2006.

Tip Sheets for Consumers and Families

Perhaps the biggest challenge facing the new drug benefit in these early days is the persistent gap between the coverage and transition obligations imposed on drug plans by CMS and what drug plans and pharmacies are doing in the real world.  It is no surprise to many NAMI members that the standards that CMS has required of drug plans and pharmacies with regard to coverage for dual eligibles is not always being followed where it really matters   (i.e. where a consumer is at a pharmacy counter being told "no.")

In order to help alleviate these problems and provide consumers and families with the tools they need to maintain continuity of care, NAMI has developed a simple one-page listing of the obligations required for all Medicare drug plans serving dual eligibles.  This "tip sheet" also has FAQs explaining cost sharing requirements (including circumstances under which cost sharing can be waived) and the process for getting a drug that is not on a drug plan's preferred list or is subject to a restriction such as prior authorization. 

NAMI affiliate leaders are especially encouraged to download this document and make it available to consumers and families.  NAMI National staff will periodically update this document since CMS is expected to issue new guidance in the coming weeks and months.

Download the Medicare Drug Plan Tip Sheet.

CMS Issues Recommendation on Plan Switching for Dual Eligibles

Because dual eligibles were automatically enrolled – on a random basis – into Medicare Part D plans, they are the only beneficiaries that have the ability to switch plans during the year (all other Medicare beneficiaries have to wait until the beginning of the following plan year).  A major problem occurred in early January for dual eligibles that elected to switch plans in late December – in most cases, their status as a dual eligible was not relayed to the new plan in which they enrolled in a timely fashion.  As a result, they were charged co-payments far in excess of the required $1 for a generic drug, $3 for a brand-name prescription.  In some instances, these dual eligibles were sent bills for monthly premiums they were not responsible for.

In order to avoid these problems going forward, CMS has put out guidance recommending that dual eligibles NOT switch drug plans late in the month in order to avoid a coverage gap at the beginning of the following month.  While attempts are being made to address the computer problems that delay effective enrollment for duals switching plans, the recommended course of action is to make the election to switch plans early in the month.  The CMS guidance on dual eligible plan switching can be viewed here.

Bills Introduced in Congress to Address Cost Sharing for Duals and Benzodiazepine Coverage

Since the beginning of the year, a broad range of legislation has been introduced in the House and Senate to address concerns with the new Medicare drug benefit.  They range from proposals to completely suspend the benefit to replacing the new program with a government managed program.  It is unlikely that any legislative proposal for major changes to the Part D benefit will get through Congress in 2006.  The Bush Administration remains firmly opposed to any major structural reforms, much less the scrapping of the entire benefit.

At the same time, there is some receptivity on the part of congressional leaders to addressing distinct problems with the new benefit while keeping the basic structure of the program in place.  Two specific bipartisan proposals that may have a chance in 2006 are cost sharing for certain dual eligibles and the mandatory exclusion of benzodiazepines.

  • Duals Cost Sharing (S 2234) – The proposal introduced by Senators Gordon Smith (R-OR) and Jeff Bingaman (D-NM) would require Medicare drug plans to waive cost sharing for dual eligibles in certain community-based residential programs such licensed group homes and other residential treatment settings (just as the law currently requires for dual eligibles in nursing homes and psychiatric hospitals).
  • Benzodiazepine Coverage (HR 3151) – The proposal introduced by Representatives Ben Cardin (D-MD) and Jim Ramstad (R-MN) would repeal the current requirement for Medicare drug plans to exclude coverage of medications known as benzodiazepines (klonopin, ativan, xanax, etc.) and allow drug plans to cover them at their discretion.  It should be noted that the vast majority of states are covering these medications for dual eligibles as allowed by CMS.

NAMI strongly supports both S 2234 and HR 3151.    A copy of NAMI's letters of support for S 2234 and HR 3151 can be viewed here.

NAMI will continue to monitor developments in Congress on legislation to amend Medicare Part D.

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