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.
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nation’s largest grassroots organization dedicated to improving the 
lives of people with severe mental illnesses. Contributions to support
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