Consumer and Family Tip Sheet Available to Help Dual Eligibles Address Coverage Problems.  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.
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