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Will Some of Medicare's Neediest Fall Between the Cracks with Start of Drug Benefit?

NOVEMBER 8, 2005 -- Some of the neediest and sickest people in Medicare already have prescription drug coverage—though Medicaid. So one of the big challenges facing federal officials in implementing the new Medicare drug benefit is to ensure the six million "dual eligibles" don't fall between the cracks when they switch from Medicaid to Medicare drug coverage on Jan. 1.

In a speech Tuesday to state Medicaid directors, Centers for Medicare and Medicaid Services Administrator Mark B. McClellan announced new steps officials are taking to lessen the odds of that happening. But not everyone is satisfied that the changeover will work well.

How might the "duals" fall between the cracks? One concern is that a dual will show up at the pharmacy on New Year's Day with no prescription drug card in hand. The main thing CMS is doing to keep that from happening is "auto-enrolling" the duals in a plan, which means duals will still be able to get prescriptions filled even if they don't choose a plan for themselves.

McClellan expressed pride in the job his agency has done identifying duals for purpose of automatically switching them into a drug plan. McClellan said there is a very close match—"way over 99 percent"—between CMS estimates of how many duals there are and the number revealed through state records.

CMS has identified 6,130,120 duals and has assigned 5,498,604 of them to randomly chosen Medicare prescription drug plans. Letters informing them of their plans were sent last week. The letters note that beneficiaries can switch to other plans if they prefer.

(Of the remaining 631,516 duals, 626,214 will get drug coverage through a Medicare managed care plan in which they are already enrolled. The rest are in jail or live outside the United States.)

But even with auto enrollment and the notification letters, officials expect some duals to fall through the cracks, because many of them are cognitively or visually impaired or suffer from low literacy, Medicaid analysts note.

If that happens, CMS said pharmacists can file an eligibility inquiry with a contractor to find the plan to which the dual belongs.
CMS announced plans Tuesday to deal with another type of dual—one who hasn't been automatically enrolled in a drug plan but who shows up at the pharmacy with cards showing they are enrolled in both Medicaid and Medicare. Under this new "point of sale mechanism" being developed by CMS the beneficiary will be able to get a prescription filled while a CMS contractor immediately confirms the dual's eligibility and arranges for his or her enrollment in a Medicare prescription drug plan, McClellan said.

The mechanism will ensure Medicare drug coverage if there is a lag between the time a person becomes a dual and when that person is actually assigned to a plan. That gap could occur when a person first becomes a dual or when the person switches in and out of dual eligibility.

David Parella, Medicaid director for the state of Connecticut, praised the new point of sale mechanism. "This is a very key issue for people," he said. Connecticut has 67,000 duals but two or three thousand are "on and off" in their eligibility. "Magnifying that across the country" generates a significant number of people who otherwise could have problems getting prescriptions filled, he suggested.

Advocates for duals also worry that the switch to Medicare coverage will require recipients to change their medications because the drugs they had been taking might not be covered on the formulary of the new plan. Medicare is dealing with that problem by requiring drug plans to have an "effective" proposal for dealing with changes in medication. One of the plans for dealing with changes in medication may be to give the beneficiary a 30-day supply of the old drug while the plan works with his or her doctor to switch to a drug on the formulary of the new plan.

But patient advocates say switches even within the same therapeutic category can be dangerous for conditions such as mental illness. McClellan said Tuesday that Medicare plans will cover all drugs for serious mental illness under a Medicare policy requiring coverage for "all or substantially" all drugs in certain therapeutic categories.

But an official with Forest Laboratories insisted otherwise. He said the company's depression medication Lexapro is taken by 40 percent of long-term care residents but that there is no mandate by CMS that Medicare prescription drug plans cover the drug.

CMS officials said that Lexepro users would be able to continue on the drug. Medicare drug plans must allow continued access to medications for a limited period of time. Doctors would have to file for an exception during that time to allow the patient to stay on the drug if it were not on the plan's formulary.

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