Medicare Drug Benefit Update
Consumer and Family Tip Sheet Available to Help Dual Eligibles Address Coverage Problems; Bills Introduced in Congress to Address Gaps.
Download the Medicare Drug Plan Tip Sheet
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. Copies 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.

NAMI E-News Alerts
are electronic newsletters provided free of charge as a public
service. With more than 1,100 state and local affiliates, NAMI is the
nation’s largest grassroots organization dedicated to improving the
lives of people with severe mental illnesses. Contributions to support
our work can be made online.
If you do not wish to receive further E-News Alerts, please click here,
sign in and uncheck the box next to Enews. Please do not reply to this
email (it will go to an unattended mailbox.) If you have any
questions, concerns, or comments, please send an email to
[email protected].
NAMI ~ 2107 Wilson Blvd. ~ Suite 300 ~ Arlington, VA 22201
<http://www.informz.net/z/cmVkOC5hc3A/dT04NDk2MTU5NCZtaT0yMzAyMjYmbD0x/index.html>
