Prescription Drug Coverage In Medicare
NAMIís Position (Summarized from the NAMI Policy Platform)
Medication prescribed for the treatment of serious mental illnesses shall be a covered benefit and shall be made available without restrictions.
NAMI Goals and Advocacy Strategies
Prescription-drug benefits must be enacted within the context of parity for mental illness treatment in the Medicare program. Currently, the Medicare copayment for Part B outpatient services is 20 percent. This copayment does not apply to mental illness treatment, however, which is covered at a rate of only 50 percent. Currently, there is also a 190-day lifetime limit for inpatient psychiatric hospital treatment. Furthermore, only office-based therapy and partial-hospitalization mental health services are allowed under Medicareís current coverage-no assertive community treatment or psychiatric rehabilitation is covered.
NAMI believes that any proposal for Medicare prescription coverage must also address the underlying discrimination in Medicareís existing, overall mental illness benefits.
NAMIís priority focus is on the 1.3 million non-elderly persons receiving SSDI benefits, 30 percent of whom are receiving them because of mental illnesses.
Prescription drugs should be a mandatory benefit for Medicare recipients, an entitlement that gives priority to non-elderly, disabled SSDI recipients.
There should be a national solution because this is a national problem, and the prescription drug benefit must be standardized nationally.
Coverage must be sufficient enough to pay for the most expensive drugs for the treatment of serious and persistent mental illnesses.
Medicare prescription drug formulary policies must comply with the NAMI policy of open access to the newer medications.
Major Priority for the Bush Administration and Congress in 2001
One of the top healthcare issues during the 2000 election campaign was the establishment of an outpatient prescription-drug benefit in the Medicare program. This issue was most commonly framed during the campaign as "coverage of prescription-drug benefits for seniors." Much to NAMIís regret, few candidates for federal office discussed this popular issue in terms of providing such coverage for the 1.3 million non-elderly people with disabilities who are eligible for Medicare by virtue of having been on Social Security Disability Insurance for a minimum of two years. When NAMI contacted both the Bush and Gore campaigns last year, we were assured that references to "drug coverage for seniors" included eligible SSDI beneficiaries.
President Bush is soon expected to put forward a two-part plan for adding a prescription-drug benefit to Medicare. The first part is a new $48 billion, four-year grant program to states willing to establish (or expand) programs to purchase drugs for low-income Medicare beneficiaries. Currently 16 states operate programs to assist eligible Medicare beneficiaries with the purchase of drugs (typically, low- and moderate income beneficiaries not eligible for coverage through Medicaid). However, half of these programs are open to only the elderly.
The second phase of the Bush program would begin after four years, and it would direct insurance companies and HMOs to offer prescription-drug coverage. This new benefit would be enacted in conjunction with larger, systemic reform of the entire Medicare program. Specifically, the plan would deliver all Medicare benefits through subsidies to private plans that would then offer coverage to beneficiaries (with outpatient prescription a required benefit). The government would not directly provide drug coverage, purchase drugs, or regulate prices. Instead, private health plans would be expected to offer a variety of options that would include drug coverage integrated into Medicare as well as "drug only" coverage added to the traditional Medicare program. These private plans would be expected to pass discounts to beneficiaries based on a federal subsidy of at least 25% of premium costs for drug coverage.
Insurers would be given enough flexibility to offer various coverage options with varying deductibles, premiums, and specific covered drugs. The government would pay any costs incurred by a beneficiary above a "stop loss" threshold of $6,000. For persons with incomes under 135 percent of the federal poverty level, the government would pay the entire premium and all of the beneficiary's costs. Medicare beneficiaries with incomes falling between 135 percent and 150 percent of the poverty level would have their premiums reduced according to a sliding scale. It is estimated that the Bush plan will cost $158 billion over 10 years, including prescription drug coverage subsidies.
On the issue of restrictive prescription-drug formularies, both President Bushís plan and most of the competing congressional proposals attempt to respond to Medicare-enrollee frustrations about access to the newest and most effective medications. All proposals would bar the establishment of a uniform national formulary for any class of FDA-approved drugs. At the same time, each proposal either explicitly or implicitly assumes that insurers will be able establish their own formularies and each will have a process to allow beneficiaries to appeal decisions to deny non-formulary drugs .
For more information about NAMIís activities on this issue, please call Andrew Sperling at 703/516-7222. All media representatives, please call NAMIís communications staff at 703/516-7963.