For plans with below-average premiums (into which Medicaid beneficiaries were automatically enrolled), average copayments in New York range from $6 for tier 1 to $69 for tier 4. Across the four states, 70 percent of plans with below-average premiums had more than three tiers, and 45 percent of plans with premiums above the benchmark had more than three tiers. The researchers recommend that indicators of beneficiary access to needed drugs be part of overall Part D performance measures. ⁽³⁾

Fund-supported researchers have been monitoring another trouble spot: the Part D subsidy designed to help low-income beneficiaries' meet their share of drug expenses. A review conducted by the Social Security Administration in January 2006 showed that more than half of applicants who qualified for the subsidy on the basis of their income were denied because their financial assets were above the maximum threshold allowed.⁽⁴⁾ The most common sources of "excess" resources were modest bank accounts, in many cases opened in anticipation of health-related expenses later in life. But according to Fund-sponsored research conducted by Dennis Shea, Ph.D., of Pennsylvania State University, low-income beneficiaries who fail to meet the Part D asset test have similar rates of chronic conditions and out-of-pocket spending to those beneficiaries who qualify for extra help.⁽⁵⁾ Shea and colleagues noted that the similarities raise questions about the fairness of the means-testing and recommended that policymakers monitor these groups carefully.

Georgetown University's Laura Summer and colleagues have been gathering data from people who work with beneficiaries across the country to identify additional problem areas and potential solutions.⁽⁶⁾ In addition to issues surrounding the low-income subsidy, Summer and her colleagues point out that Part D rules may make it too costly for many beneficiaries to continue receiving long-term care in community settings rather than in nursing facilities, where residents are protected from copayments and other drug costs. Eliminating the copayment requirements for community-dwelling "dual eligibles" (low-income Medicare beneficiaries who were previously enrolled in Medicaid), as some in Congress have proposed, would be one way to allow such individuals to avoid institutionalization. Another serious issue—and one that affects all beneficiaries—is the general lack of assistance with using the new drug benefit, including accurate, easy-to-use information about private drug plan options, and help with applying for the low-income subsidy and enrolling in a plan.