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CMS Announces Additional Steps to Ensure Drug Coverage for Duals

DECEMBER 1, 2005 -- Medicare "dual eligibles" who are not automatically enrolled in the new Medicare drug benefit or have not selected a plan for coverage by Jan. 1 will still be able to have their prescriptions filled, government officials said Thursday.

The Centers for Medicare and Medicaid Services has contracted with Wellpoint, which has a pharmacy network that covers all 50 states, to manage a single national account for payment of drug claims for what is expected to be a limited number of dual eligibles who have not picked a plan or been automatically enrolled in one by the time the new Medicare drug benefit begins.

CMS' plan, according to documents released Thursday, would allow beneficiaries who can present proof of eligibility for both Medicare and Medicaid—but who are not enrolled in a Medicare drug plan—to have their claim for medication submitted to a single account for payment, with the CMS contractor immediately following up to validate eligibility and enroll the beneficiary in a drug plan.

"CMS and its contractor will provide a uniform and straightforward set of instructions that all pharmacists can follow no matter which plan network they are in or where they are in the country," according to a CMS fact sheet on dual eligible coverage.

CMS has been under fire for its plans to move the dual eligibles, who qualify for both Medicaid and Medicare, into Medicare for their drug coverage, as required by the new drug law (pl 108-173). On Nov. 17, Sen. Max Baucus, D-Mont., said preliminary findings from a Government Accountability Office report he had requested showed problems with CMS' plans to switch dual eligibles from Medicaid drug coverage to the new Medicare prescription drug benefit. In addition, eight consumer and health care advocacy groups have sued the federal government, charging that its plans for dual eligibles drug coverage are inadequate.

CMS Administrator Mark B. McClellan said Thursday that CMS' plan to provide drug coverage to duals who either had not enrolled in a drug plan or had not selected one "does not have any specific relationship to the lawsuit" and has been under development for months. "It's absolutely being finalized today. It's not a late add-on," he said in a conference call with reporters.

Deene Beebe, director of communications for the Medicare Rights Center, one of the groups suing CMS, praised the announcement but said her group remained concerned that duals be able to get access to the drugs they need.

"We just want to be sure that every dual that walks into a drug store with a prescription to be filled walks out with their medication," Beebe said. "If CMS can foresee all the troubles and find remedies for all of them, that would be terrific."

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