Announcements on the Part D Crisis January 15, 2006
California Senator Don Perata (D - Oakland)
United States Senator Diane Feinstein (D- CA)
Governor Arnold Schwarzenegger
California Department of Health Services - January 17, 2006
The Disability Policy Collaboration Action Alert
CDCAN Report
A Guide to Medicare Part D for People with Developmental Disabilities - January 15, 2006
From the ArcLink - January 14, 2006
 
Medicaid Part D - Q & As (CMS) - Sept 8, 2005
Medicare Prescription Drug Benefit
The MedCard
Previous Rule Making Activities
Resources for CCD Medicaid Workgroup
The Impact of Medicaid Reform on People with Disabilities
Dual Eligibles (PowerPoint)
California Legislative Analyst Office Report - March 16, 2005
Update from The Arc - March 17, 2005
New Data Reveals No Savings - March 17, 2005
CMS MMA Guide to State Legislators - March 17, 2005

 

The Arc of California
Medicare and MediCal Page
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 NOTE TO CHAPTERS/AFFILIATES: All complaints from dual eligibles experiencing problems during this transition must be filed with CMS. However, it would be helpful to document situations from those who suffer adverse health consequences because of the transition. Liz Savage at the Disability Policy Collaboration (savage@thedpc.org) is working with CMS on its transition policies and needs examples of these types of situations.

PART D MEDICARE TRANSITION PROBLEMS
HAVE SOLUTIONS

The January 1 transition of 6.4 million dual eligibles (including 500,000 individuals with developmental disabilities) from Medicaid prescription drug coverage to the new Medicare Part D coverage has been problematic from some, despite the extensive nationwide outreach efforts to educate beneficiaries, their families, providers and pharmacists.

Advocates should know that the Centers for Medicare and Medicaid Services (CMS) established protections to ensure that dual eligibles will not leave the pharmacy without their medications. CMS is working with the Part D prescription drug plans (PDPs) and pharmacists on implementation of these critical protections. Below are four examples of common problems and suggestions for resolving them to ensure that dual eligibles have access to their medications.

Problem #1) The pharmacist tells the beneficiary that their drugs are not on the formulary (list of approved drugs) of the Part D prescription drug plan in which the dual eligible was auto-enrolled or that the drug is subject to prior authorization by the PDP and cannot be dispensed without the PDP’s approval.

Solution - The Centers for Medicare & Medicaid Services (CMS) expects all PDPs to provide a “first fill” or 30-day supply of non-formulary drugs. This is known as the PDP’s “transition policy.” CMS sent a “reminder” letter to the PDPs, which can be found at http://www.thedesk.info/partD/transition.htm.  If questions arise about the PDP’s transition policy, the pharmacist should call the PDP’s technical assistance line or the CMS Pharmacy Help Line.

NOTE: During this 30-day transition period, dual eligibles should seek assistance (e.g. by calling 1-800-MEDICARE (1-800-633-4227) in choosing a PDP with a drug formulary that includes all of their medications or seek assistance from their medical providers in the event that a plan covering all of their medications cannot be found.

Problem #2) A pharmacist charges the beneficiary for the Part D deductible and/or a high co-pay.

Solution - Dual eligibles are not required to pay deductibles under Part D. If a dual eligible’s income is under 100 percent of the federal poverty level ($9,570 annually for an individual), he or she is required to pay $1 for each preferred (usually generic) medication or $3 for each non-preferred (usually brand name) medication as described by the PDP. If an individual’s annual income is above 100 percent of the federal poverty level, then the co-pay is $2 for the preferred medication and $5 for the non-preferred. A dual eligible residing in ICFs/MR or a nursing facility will not be required to pay co-pays. Pharmacists can query the CMS computer system or call the CMS dedicated pharmacy eligibility line to determine Part D plan enrollment.

Problem #3) Some dual eligibles have not received their PDP identification (ID) card because they switched plans in mid-to-late December. Dual eligibles take their new PDP’s “acknowledgment letter” to the pharmacy or go to their pharmacy without an “acknowledgment letter,” but the pharmacist will not fill the prescription without the ID card.

Solution - Pharmacists can query the CMS computer system or call the CMS dedicated pharmacy eligibility line to determine Part D plan enrollment

Problem #4) A dual eligible comes to the pharmacy with only a Medicaid card and appears Medicare eligible but the pharmacist cannot determine if the beneficiary has been auto-enrolled in any plan.

Solution - If the pharmacist believes the individual is a dual eligible and cannot get confirmation from the CMS computer software program, the point of service contractor (Anthem) can be billed.

The Disability Policy Collaboration (DPC) is working closely with CMS to ensure that all dual eligibles obtain the prescription drugs they need. This critical information should be disseminated to chapter/affiliate networks, civic organizations, religious groups, and others who can reach people outside the immediate DPC network.

A new section has been added to the DPC’s Medicare Part D Web site (http://www.thedesk.info/partD/) with more information about transition policy.
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Important clarification for Members of the Olmstead Advisory Committee and Interested Parties-
 
It is important to clarify that this emergency drug coverage will impact approximately 200,000 dual eligibles (those eligible for both Medicare and Medi-Cal) who have not been receiving the medications they need - not to be confused with the entire dual eligible population. Thank you and my apologies.

Because of the problems California's dual eligible population is having in accessing prescription drugs under the new federal Medicare Part D program, Governor Schwarzenegger today announced his decision to provide temporary, emergency coverage of prescription drugs for dual eligibles who are unable to obtain them through their Medicare coverage. Please see the press release attached below.

Governor Schwarzenegger Takes Action to Ensure California's Most Vulnerable Residents Get Necessary Medications

GAAS:032:06
For Immediate Release:                                                           
Contact:  Margita Thompson
Thursday, January 12, 2006                                                                      
Julie Soderlund 916-445-4571
Nicole Kasabian Evans, HHS 916-654-3304

Governor Arnold Schwarzenegger today provided temporary emergency prescription drug coverage to the nearly one million Californians dually eligible for Medi-Cal and Medicare who are unable to obtain medications due to transition problems at the federal level to Medicare drug plans. Legislative leaders today also committed to introduce legislation next week to appropriate funding for an initial 15-day emergency drug coverage for dual eligible beneficiaries.

"I took emergency action to ensure seniors and disabled Californians get lifesaving medications they are in danger of losing because of significant problems with the new federal Medicare prescription drug program," said Governor Arnold Schwarzenegger. "Prescription drug coverage for people on Medicare and Medi-Cal is a federal responsibility but under these extreme circumstances, I have ordered that the state temporarily pay for their drug coverage. While I am confident the federal government will resolve the problems with this transition, these people need our help now and we're going to be there for them. I am also calling on the federal government to reimburse California for the cost of this action because they are accountable for this program and for ensuring these vulnerable Californians have the prescription drugs they need."

The Governor has directed the Department of Health Services to immediately implement a 5-day emergency program to pay for prescription drugs for beneficiaries who have been unable to obtain them through their Medicare coverage pending legislative action next week to extend the coverage for another 10-days.  Starting later today, the state will be the payer of last resort. To receive reimbursement, a pharmacy must certify that it was either unable to obtain necessary information from Medicare to submit a claim, its claim was incorrectly denied or that the beneficiary's deductible or co-payment was higher than the $1 to $5 amount established by Medicare. The Governor will also ask the federal government to reimburse the state for the cost of this emergency program.

"In response to the problems our residents are having accessing the prescription drugs they need, Governor Schwarzenegger has decided to take bold action to provide temporary, emergency coverage of prescription drug benefits for the nearly one million Californians who are dually eligible for Medi-Cal and Medicare," said Health and Human Services Secretary Kim Belshé.

On January 1, 2006, under the Medicare Modernization Act, the federal government took responsibility for prescription drug coverage for the nearly one million Californians dually eligible for Medi-Cal and Medicare. The transition of these individuals to federal Medicare plans in just one day resulted in an error rate of 20 percent. This means 200,000 vulnerable Californians are not receiving the medications they need. In addition, dual eligibles and pharmacies facing problems and attempting to clarify eligibility and Medicare drug plan enrollment have experienced long waits while trying to obtain information from Medicare's overloaded phone lines.

 

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From TheArcLink:
 
The transition of people who are eligible both for Medicare and Medicaid to the new Part D prescription drug benefit has been difficult. Dual eligible and low-income Medicare beneficiaries around the country were overcharged, and some were turned away from pharmacies without getting their medications in the first week of Medicare's new drug benefit. The problems have prompted emergency action by at least ten states to protect their citizens.
 
Claims that were supposed to be paid by insurance companies participating in the new Medicare prescription drug benefit, which began January 1 have been picked up by these states on a temporary basis until the problems get worked out.
 
Solutions to these problems are apparently in the works. To see an analysis of the problems, and to see what you should do if you have problems with Part D, go to http://theDesk.info/PartD. This information on this site is produced by the Disability Policy Collaborative, a partnership of The Arc and United Cerebral Palsy, and is being updated on a regular basis. The site is sponsored by TheArcLink Incorporated..
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from Senator Don Perata (D - Oakland) - January of this year marked the first time the federal government has offered prescription drug coverage through the Medicare program. As a state representative, I have long believed the Bush prescription drug program is seriously flawed.  It's confusing, cumbersome, and rife with gaps in coverage for seniors who need the help most. 

But only last week -- after receiving a number of calls from low-income seniors and the disabled who had difficulty getting life-sustaining presciption drugs -- did I realize just how dangerously flawed the Bush prescription drug program is. 

The federal prescription drug program apparently began without all the bugs being worked out.  Two hundred thousand low-income seniors and people with disabilities who previously had coverage have been left behind, due to computer problems and other administrative errors. These are people who require insulin, heart medication and other life-preserving drugs.

On Wednesday afternoon, an hour or two after the program was brought to my attention, I brought my concerns to the governor. While the program is a federal program, I told the governor that state cannot stand by and watch its most vulnerable residents suffer for the Bush administration's mistakes.

During our meeting, the governor gave an emergency directive to the state Department of Health Services, telling them to use state money to pay for this federal program and ensure low-income seniors and the disabled access to their prescriptions. 

This week, I will introduce emergency legislation to extend California’s coverage to the low income and disabled for a longer period of time.  This emergency action costs the state as much as $10 million a day -- money that threatens state programs like child care, in home supportive services for the elderly and disabled, and crucial education funding.  As a result, I will, with my collegues and the governor, demand that the federal government fixes the Medicare Part D system and reimburses the state for stepping in where the federal government has failed.

Please help me to help inform our low-income and disabled residents that they can now get their drugs from any pharmacy that participates in the program.  And please help me and my colleagues get the state's money back from the federal government.  Send your e-mail to me supporting federal reimbursement.  I will present the notes to federal leaders to demonstrate public support for reimbursement.

As always, thank you.

 

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Update from The Arc - March 17, 2005
Today, the CMS Administrator, Mark B. McClellan, M.D., Ph.D., released two guidance documents for Medicare prescription drug plans (PDPs) and Medicare Advantage plans (MA-PDs) that will provide prescription drug coverage starting in January. (See attachments.)

The first document details the medication transition plans that PDPs and MA-PD plans will need to submit to CMS as part of their formulary system.  The transition plans are meant to accommodate beneficiaries who are stabilized on existing drug regimens when they join a Part D plan.  This guidance addresses the transition for all beneficiaries who will join Part D plans on January 1, 2006 as well as later cases when beneficiaries either first join the Medicare program or when they switch from one Part D plan to another. CMS is committed to making these transitions smooth for all involved. The guidance demonstrates CMS's expectation that plans will allow new enrollees to receive temporary one-time fills of existing medications that may not be on the new plan's formulary in order to allow time for beneficiaries, their pharmacists and their doctors to work out an appropriate therapeutic interchange or request a permanent exception to the plan's formulary. Plans may also adopt other appropriate transition strategies. The guidance also addresses the particular needs of enrollees who reside in long-term care facilities.

The second document addresses pharmacy participation standards and access standards for beneficiaries residing in long-term care facilities. These minimum performance and service standards -- which reflect current industry practice -- include requiring a long-term care pharmacy to have a comprehensive inventory of drugs commonly used in a long-term care setting, the ability to package the medications in the unit-of-use packaging typically used in nursing homes and be able to provide a qualified pharmacist to be on-call 24-hours a day, seven days week, including holidays. In addition, the guidance addresses what CMS views as "convenient access" to nursing home pharmacies as required by our regulation. CMS will work with PDPs and MA-PD plans all during the Spring and Summer application and bid process to make sure that they construct a network of nursing home pharmacies with sufficient range to reach all future institutionalized Part D enrollees in their service area.

The guidance today forms another part of our commitment to an effective implementation of the prescription drug coverage. We will continue to seek input from all stakeholders, with the goal of a smooth transition to this important new benefit which for the first time will help all Medicare beneficiaries pay for the drugs they need.
 
Transition Process    Long Term Care Guidance    Transition Fact Sheet
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The U.S. Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) today issued the final regulations implementing a new prescription drug benefit that will help people with Medicare pay for the drugs they need, announced Secretary Tommy G. Thompson and CMS Administrator, Mark B. McClellan, M.D., Ph.D. 
 
This benefit begins in January 2006 and allows all Medicare beneficiaries to sign up for drug coverage through a prescription drug plan or Medicare health plan. The final regulations also provide new protections for retirees who currently receive drug coverage through their employers or unions, and they strengthen the Medicare Advantage program.
 
To develop the final regulations implementing the Medicare prescription drug benefit, CMS relied on the expertise, input and recommendations from individuals and organizations such as consumer and beneficiary advocates, health plans, pharmacies, pharmaceutical benefit managers, actuaries, states, health care providers, employers, unions, and other affected groups and experts.  In addition, thousands of written comments and an extensive series of public meetings, including Open Door Forums, provided CMS with helpful advice and information in response to the proposed regulations that were published in August 2004.
 
Attached are a press release and two fact sheets that explain the final regulations in detail and summarize the changes made from the proposed rule.  Extensive additional information including fact sheets about the drug benefit and Medicare Advantage, and the regulations themselves, can be found at www.cms.hhs.gov. 
 
HHS Takes Major Steps To Prescription Drug Benefit
MediCare Fact Sheet
Principle Changes

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The MedCard

The Medicare Drug Discount Card Guide
- Related Advocacy -
Please visit this easy-to-use guide at www.themedcard.info for people with disabilities.  If you already receive Medicare benefits you may be eligible for a drug discount card, but if you have Medicaid you may not be eligible. Because of the complex guidelines, it is hard to figure out if you should apply for the card, and if you can get one, why would you want one. The web site makes it easier.

TheMedCard project was made possible through a grant from the Administration on Developmental Disabilities, Administration for Children and Families, Department of Health and Human Services to The Arc of the United States. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration on Developmental Disabilities policy.

The web site was developed by TheArcLink Incorporated, in collaboration with National Center on Self-Determination and 21st Century Leadership at Portland State University and Oklahoma People First. TheArcLink is a joint venture with The Arc, The Arc of Indiana and the Stone Belt Arc in Bloomington, Indiana.

TheMedCard also links to other independent sites about the drug discount card, like the Access to Benefits Coalition site at www.accesstobenefits.org.  In addition to the clear explanations about the card, all the text on the site was converted to brief audio and video clips so that people with intellectual disabilities and others who have trouble reading can also get all the information even if their computers do not have screen readers.
 

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   UCP: Understanding Disabilities Creating Opportunities

 

 

 

Public Policy

Collaboration

 Proposed Medicare Rules Fail to Protect Beneficiaries with Disabilities;

Dual Eligibles at Risk

Some folks are having trouble sending their comments via the CMS Web site.
See feedback from CMS below:
To address your problem, you just need to fill out all required
screens/fields and if you still can't gain access, call Tony Mazarella at 202 690-8390 or 410 786-3200.
 

Your Comments to CMS Needed Urgently by October 4th to Win Changes 

The Arc of California Letter     Sample Advocate Letter     The Public Policy Collaboration Alert Letter         

 

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