 AsclepiosYour Weekly Medicare Consumer Advocacy Update The Part D Lottery A lot of people with Medicare and Medicaid were surprised to learn this month that the Medicare drug plan they were assigned did not cover the drugs they take. Why would the federal government stick them into a plan at random, without considering whether it met their needs? It does not make sense. The rest of Medicare—Part A, which covers hospital visits, and Part B, which covers doctor visits—doesn’t work like this. Expensive heart surgery is covered, and so is a simple doctor evaluation for someone who feels dizzy after walking up the stairs. That guarantee evaporates in the world of Part D, where the for-profit insurance company offering the drug plan decides which drugs it will pay for and which it won’t. And every plan decides differently. A paper by the Connecticut Health Foundation looked at the drug coverage offered by the 44 prescription drug plans available in the state for three types of people with Medicare—someone with schizophrenia and associated mental illnesses, a person with HIV/AIDS and related conditions, and a “prototype” older adult with multiple conditions, including high blood pressure, high cholesterol and arthritis. The study found “sharp and random variation” in the drugs these plans cover and the co-payments they charge. A person with HIV/AIDS and a moderate income that makes them ineligible for the Extra Help program would pay over $12,000 per year under the highest cost plan and $5,000 for the lowest cost plan. An older adult with multiple conditions would pay more than $6,000 under one plan, but a little over $3,000 under another. Can’t people just pick the cheaper plan? Yes, they can, assuming they can get good information on what the plans cover, what restrictions they impose on coverage and what the copayments are. They get one chance to choose and one chance to switch before May 15. (People who qualify for Extra Help or are institutionalized can switch plans monthly.) Unfortunately, people cannot predict if they will get sick months into the future and what condition they will have. And that is where a system supposedly based on “freedom of choice” breaks down. The Connecticut survey found that it was not easy to predict how plans would cover drug regimens for different conditions. “For example, four of the ten ‘worst’ plans for the person with schizophrenia did a better-than-average job covering the medications of the prototype senior,” the paper said. People who find themselves stuck in the wrong plan have two other options. They can appeal for coverage and take their chances that the plan will change its mind or an independent arbitrator will overrule the plan. This is not a viable option for most people with Medicare. Or they can ask their doctor to switch their medicines and hope that the new drugs work just as well. That option has a better chance of working if the plans’ coverage and copayment decisions are based on medical evidence and not on profits driven by things like the secret rebates they receive from drug manufacturers. If the plans were basing coverage decisions on medical evidence, there would be a lot more similarities in what they cover. Medical studies, after all, are published in peer-reviewed journals. The deals plans strike with manufacturers to push certain drugs are not. A drug benefit that was delivered through Medicare and not through private plans could use medical evidence to decide what drugs are covered and the market clout of 43 million people with Medicare to negotiate lower prices. That’s our best bet for drug coverage that works for everyone. Angry? Inspired? Send a letter to your local newspaper. Medical Record “For example, four of the ten ‘worst’ plans for the person with schizophrenia did a better-than-average job covering the medications of the prototype senior. As such, the review highlights that the best plan for an individual often is a highly specific function of the particular medication needs” (“Medicare Modernization Act: An Early Look at Medicare Drug Plan Options for Connecticut’s Medicare Beneficiaries,” Connecticut Health Foundation, December 2005). People with Medicare and Medicaid, so-called “dual eligibles,” randomly assigned to a Medicare drug plan are at particular risk of finding that the drugs they need are not covered by their new plan. If they sign up on their own, they have a greater chance of selecting a plan that covers the drugs that they need. While the law allows dual eligibles to switch plans throughout the year, it may be some time before they learn about this option. (“The New Medicare Prescription Drug Law: Issues for Enrolling Dual Eligibles into Drug Plans,” Kaiser Family Foundation, January 2005). “I am a 42-year-old, disabled man with Medicare and Medicaid. Out of 10 prescriptions, the plan I was automatically enrolled in still refuses to fill all but four of them. The other six are either being covered for half the quantity I need for a month, or not being covered at all! I have tried to contact my local Medicaid Office, in order to try to get them covered and I cannot even get through” (Submission to the Part D Monitoring Project from Coral Springs, Florida, January 2006). Fast Relief: Medicare Part D Monitoring Project The Medicare Rights Center (MRC) needs to hear about all the problems with the Medicare Part D benefit, whether they happen to you or someone in your community. With this information, we will be armed with the needed evidence to push for a decent Medicare drug benefit. Submit your story at www.medicarerights.org/partdstories.html. Help Us Eliminate the 24-Month Waiting Period for Medicare Many people know that Medicare serves both older adults and people with disabilities. Few are aware that Americans with disabilities must wait 24 months from their first Social Security disability income payment, which is five months after Social Security deems them disabled, before their Medicare coverage begins. Medicare provides an invaluable safety net for Americans with disabilities, providing good, affordable health coverage when the private insurance market turns its back. Let us work together to make this health coverage available as soon as people need it, rather than 24 months later. Help us eliminate the 24-month Medicare waiting period. The Medicare Rights Center is committed to eliminating the Medicare coverage waiting period and we have recently embarked on a national media project to do so. Our goal is to focus attention on the personal experiences of people who are currently in the 24-month Medicare waiting period; or finally got Medicare coverage after having gone through the two-year wait. These individuals would have to be comfortable talking to the press about their health care experiences during the Medicare waiting period. If you know of individuals with a compelling story who are willing to participate in this project, please contact Heidi Kreamer at 800-333-4114, ext. 33 or hkreamer@medicarerights.org. The Louder Our Voice, the Stronger Our Message Asclepios—named for the Greek and Roman god of medicine who, acclaimed for his healing abilities, was at one point the most worshipped god in Greece—is a weekly action alert designed to keep you up-to-date with Medicare program and policy issues, and advance advocacy strategies to address them. Please help build awareness of key Medicare consumer issues by forwarding this action alert to your friends and encouraging them to subscribe today. The Medicare Rights Center (MRC) is the largest independent source of Medicare information and assistance in the United States. Founded in 1989, MRC helps older adults and people with disabilities get good, affordable health care.
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