Asclepios               

Get Asclepios free by e-mail every week! Click here to subscribe.


Reality Check
October 5, 2006 • Volume 6, Issue 40

When people with Medicare learn that their Part D prescription drug plan denies or restricts coverage for one of their medicines, is the plan required to provide a temporary supply of the drug until an appeal for coverage is decided?

Advocates who have spent much of the last nine months fighting to obtain coverage of medicines needed by people with Medicare know the answer to that question is "No." Their clients have gone without medicines, skipped doses or relied on free supplies from their doctors while their appeals for coverage dragged on. Others have scraped together the cash from their limited incomes to pay for their expensive medicines (it is the high- priced drugs that tend not to be covered or are subject to restrictions by the Part D plans).

That's the view from the trenches; the picture from on high is considerably rosier.

Last month, the Bush administration's top Medicare official, Centers for Medicare & Medicaid Services (CMS) Administrator Mark McClellan, wrote consumer advocates a letter asserting that "plans must cover a temporary supply while claims are being adjudicated." McClellan goes on to say that plans must continue to cover drugs if they fail to meet the deadlines established for the appeals process.

Those claims had many consumer advocates scratching their heads, wondering how the top Medicare official's picture of Part D and the reality on the ground could be so different. It is true that CMS does require Part D plans to provide a one-month temporary supply to new members when their drugs are not covered and has established mandatory timelines for hearing appeals. But, whatever McClellan may believe, those requirements do not guarantee that vital medicines will be covered while an appeal is being heard. Here are some of the reasons why:

Left in the lurch are people with Medicare who depend on their Part D plan to cover medicines for a serious illness, from hypertension to schizophrenia. When drug treatment is interrupted, people can wind up sick, in the emergency room or worse.

It is also important to recognize that most people with Medicare deal with the coverage restrictions imposed by the Part D plans without the help of an advocate familiar with all the regulations and with the contacts necessary to get CMS to intervene when a Part D plan fails to meet its requirements. Most people never even appeal for coverage. That is evident in the low number of appeals, even though there is ample proof that many drugs commonly used by people with Medicare, especially poor people with Medicare, are not covered or are restricted by the Part D plans.

People with Medicare need a drug plan through Medicare that will cover the medicines they require at affordable prices without making them jump through a lot of hoops under an appeals process. Enacting that benefit into law will be up to the next Congress. In the meantime, the Bush administration needs to get a grip on reality and do what it takes to make sure that Part D provides people with Medicare the medicines they need when they need them.

Medical Record

“Your letter notes CMS' expectation that plans on a case-by-case basis will extend temporary supplies beyond the 30 day minimum when exceptions or appeals requests remain unresolved. In our experience, unless CMS clearly mandates out minimum obligations for Part D plans, such expectations are not likely to be realized. Without mandated minimum protections for beneficiaries, advocates and CMS caseworkers have no means of ensuring that plans meet their obligations" (Letter to Mark McClellan from Center for Medicare Advocacy, National Senior Citizens Law Center, Medicare Rights Center, et al., October 3, 2006).

"Since January, there have been less than 0.5 reconsideration (2nd level appeal) requests per 1,000 beneficiaries, and nearly all reconsideration requests filed by people with Medicare were decided within seven days as required by CMS guidelines" ("Enhanced Tools Available to Help People With Medicare Improve Their Health Care," CMS press release, September 21, 2006).

“In a comprehensive review of Part D formularies, the Office of the Inspector General (OIG) identified 200 of the most commonly used drugs by [people eligible for both Medicaid and Medicare]. Our assessment included 15 antidepressants and 9 antipsychotics on the OIG's list. Overall, this subset of 24 drugs had an average utilization management rate of 38 percent, which was greater than the overall average utilization management rate of 23 percent” (“Clearing Hurdles and Hitting Walls: Restrictions Undermine Part D Coverage of Mental Health Drugs,” Medicare Rights Center, September 2006).

*****

Fast Relief: Part D Monitoring Project

The Medicare Rights Center (MRC) needs to hear about all the problems with the Medicare Part D benefit, whether they happen to you or someone in your community. With this information, we will be armed with the needed evidence to push for a Medicare-administered drug benefit.

Submit your story at www.medicarerights.org/partdstories.html

*****

The Louder Our Voice, the Stronger Our Message

Asclepios — named for the Greek and Roman god of medicine who, acclaimed for his healing abilities, was at one point the most worshipped god in Greece—is a weekly e-newsletter designed to keep you up-to-date with Medicare program and policy issues, and advance advocacy strategies to address them. Please help build awareness of key Medicare consumer issues by forwarding this action alert to your friends and encouraging them to subscribe today.

Please send all replies and subscription requests to mrcadvocacyupdate@medicarerights.org.

Get Asclepios free by e-mail every week! Click here to subscribe.

_________________________________