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Stark Plans Part D Changes in Medicare Bill

By John Reichard, CQ Health Beat Editor

July 21, 2007 -- House Ways and Means Health Subcommittee Chairman Pete Stark, D-Calif., said Thursday he hopes to move legislation this summer that would tighten oversight of drug coverage plans offered under the Medicare Part D prescription drug program. Provisions may include language giving state insurance regulators authority to oversee insurers marketing the plans, requiring public disclosure of enforcement action taken against drug plans that violate Medicare regulations, and mandating coverage of benzodiazepines, a category of drugs used to tranquilize nursing home patients, among other uses.

Another provision would require the same open enrollment periods for the two types of drug coverage offered in the Part D program: stand-alone prescription drug plans, or "PDPs," sold to beneficiaries in traditional Medicare; and "MA-PDs," the prescription drug plans offered as a part of the private health plans sold through the Medicare Advantage program. Stark also would put in statute the current Medicare regulation requiring drug plans to cover six therapeutic categories of drugs.

Stark laid out the specifics at a hearing to examine how well the Part D program is working. "I hope this . . . will lay the groundwork for improvements to Part D that may be included in the Medicare sections of forthcoming health legislation we hope to move this summer," he said in his opening statement.

More broadly, Stark said his goal is to make it easier to compare drug plans, but he didn't specify whether he will seek to do so in the legislation, which also is expected to trim Medicare payments to a range of providers to pay for coverage of uninsured children. "I hope we can at least talk about standardizing Part D products so beneficiaries are better able to compare the 50 or more plans available in their communities," he said.

Witnesses at the hearing described a variety of improvements that need to be made to Part D, including smoother access to AIDS medications, ensuring accurate premium deductions from Social Security checks, and ending delays in enrolling the most frail Medicare beneficiaries in drug coverage plans.

Leslie Norwalk, acting administrator of the Centers for Medicare and Medicaid Services, said that ensuring accurate premium deductions is the number one remaining implementation problem the agency faces. She said that there is no "quick fix" for the problem, which occurs in some cases when beneficiaries first sign up for coverage.

Kathleen King, health care director at the Government Accountability Office, said that it takes up to five weeks to complete the enrollment of certain "dual-eligibles"—Medicare beneficiaries who also qualify for Medicaid benefits—when they first enter the Part D program. Because of delays in getting pharmacies up-to-date enrollment information, beneficiaries may have difficulty getting their prescriptions filled during that period, she said. King said the problem primarily affects people who first qualify for Medicare and later for Medicaid. She estimated the problem affected some 400,000 beneficiaries this year.

"CMS did not fully implement or monitor the impact of this policy," King said. "Although beneficiaries are entitled to reimbursement for covered drugs during this retroactive period, CMS did not begin informing them of this right until March 2007," she said. She estimated that plans were paid a total of $100 million for periods in which beneficiaries may not have been able to get prescriptions filled and for which they may or may not have later sought reimbursement.

Stephen O'Brien, medical director of the Alta Bates Summit Bay AIDS Center in Oakland, said many of the patients he treats have experienced problems with the Medicare drug benefit. "Patients have had trouble accessing anti-retrovirals and treatment for opportunistic infections," he said. "Patients have gone without medications they can't afford or can't access through their new plans. Changes in plans have caused disruption in patients' access to long-term medications." Many doctors who treat AIDS patients say they are worse off under Medicare than they were under Medicaid, he added.

O'Brien emphasized the seriousness of the problems. Successful suppression of the AIDS virus requires uninterrupted use of anti-retroviral drugs, he said. But access problems aren't limited to anti-retroviral drugs. "Many patients have had difficulty receiving the anti-fungal fluconazole to treat cryptococcal meningitis," he said, which has led to "prolonged hospitalizations and gaps in treatment."

Paul Precht, policy director of the New York City–based Medicare Rights Center, said based on calls his center has received, beneficiaries are having difficulty getting enrolled, getting access to affordable medications, and obtaining coverage for medications once they are enrolled in a Part D plan. Precht said for example that "recently, we have been working to prevent people with Medicare from being dropped by their Part D plan for non-payment of premiums. These individuals are having Part D premiums deducted from their Social Security checks, but because of system problems, premiums are not finding their way to Part D plans."

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