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Fixing the Drug Benefit
January 29, 2009 • Volume 9, Issue 4
This week, leading congressional Democrats reintroduced the Medicare Prescription Drugs Savings and Choice Act, a bill to provide a prescription drug benefit under Original Medicare. If enacted, the legislation would create a government run coverage option that would provide real choice for people with Medicare who now can only receive coverage through a private plan.
Creating a benefit under original Medicare is essential to providing reliable, stable standardized coverage that assures access to medically necessary medications. Currently, private plans change what they charge and what drugs they cover year to year, making drug coverage for Part D enrollees unpredictable and inconsistent.
Fluctuating premiums destabilize coverage for individuals with limited income who receive Extra Help, a federal program to help cover the out-of-pocket drug costs for people with Medicare living under or just above the poverty level. Medicare randomly reassigns most individuals with Extra Help annually to a new Part D drug plan if their current plan will no longer qualify for a full-premium subsidy. This year alone over one million people with Medicare were reassigned due to increases in premiums by Part D plans.
Randomly reassigning people receiving Extra Help to new Part D plans may have serious health implications for individuals. Because Part D plans have wide discretion to decide which drugs they cover and what restrictions they place on coverage, a randomly assigned new plan may not cover an individual’s medications, causing an interruption in treatment.
A Medicare-run drug benefit will have the ability to negotiate lower drug prices—just like the Veterans Administration does—and be able to offer a low premium that is uniform nationwide. It will create stable coverage for all people with Medicare, including individuals with limited income enrolled in Extra Help. A drug benefit under Original Medicare would provide a consistent formulary. The proposed legislation would prevent drugs from being removed from the formulary mid-year but would allow new medications with clinical benefits to be added.
A Medicare option will provide consumers a refuge from the greed and ineptitude that has plagued drug benefit administration by many private plans. Most recently, WellPoint, the nation’s largest health insurance provider, was sanctioned by the Centers for Medicare & Medicaid Services (CMS) because of internal system failures relating to the company’s Part D plan. Thousands of people with Medicare who are enrolled in a WellPoint plan have been unable to access their prescriptions at the pharmacy, were charged improper premiums and co-payments, did not receive plan information such as formulary restrictions, and may have been unable to access the appeals and grievance processes, among other violations.
The proposed legislation provides an option of obtaining coverage through Original Medicare, a program trusted to provide good affordable health insurance for 44 years. The new benefit would create a more efficient appeals process, giving people with Medicare greater flexibility to quickly obtain coverage for medically necessary medications that are subject to formulary restrictions.
A new Congress means a new opportunity to revisit important reforms to the Medicare program. A drug benefit under Original Medicare would allow greater savings and access to needed treatments for older Americans and people with disabilities. Please ask your senators and representative to cosponsor the Medicare Prescription Drugs Savings and Choice Act.
“[T]he legislation, sponsored by Senate Majority Whip Richard Durbin (D-Ill.) and Reps. Marion Berry (D-Ark.) and Jan Schakowsky (D-Ill.), would strengthen the ability of Medicare beneficiaries to appeal denials of coverage for medically necessary medications under all Medicare Part D plans.” (House Democrats Introduce Legislation That Would Allow Medicare To Offer Prescription Drug Plans That Compete With Private Plans, Kaiser Daily Health Policy Report, Capital Hill Watch, January 2009)
“The high cost of prescription drugs has made it hard for many low-income seniors to afford the medications their doctors recommend while keeping up with the rest of their bills. They deserve an affordable drug benefit . . . Our legislation will provide an alternative that requires the Administration to negotiate on behalf of seniors to bring down the costs of needed medications.” (Senator Richard Durbin (D-IL) as quoted in Durbin, Berry, Schakowsky Work to Lower Prescription Drug Costs for Seniors, January 2009)
“People with Medicare are feeling the impact of the decision by Congress to hand the drug benefit to private insurance companies instead of administering it through the Medicare program. Older adults and people with disabilities are finding that their medications are not covered and they’re facing obstacles when they appeal for coverage. Many people are experiencing more restrictions and paying higher co-payments than they did with the coverage they had prior to the implementation of Part D.” (Add a Drug Coverage Option to Original Medicare, Medicare Rights Center, January 2009)
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Medicare Part D Appeals Help for Advocates Is Here!
Medicare Rights Center’s new Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process offers an easy-to-understand, comprehensive overview of the entire appeals process, including real-life case examples, a glossary of important appeals terms, a sample protocol for advocates, and links to important resources.
Register for a FREE copy of this great resource.
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Medicare Part D Monitoring Project
would like to hear about your experience, or that of someone you know, enrolled in a private drug plan. With information about what the issues are with Medicare Part D, we will be able to demand that those problems be fixed. Medicare Rights Center
Submit your story at http://www.medicarerights.org/about-mrc/newsletter-signup.php.
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The Louder Our Voice, the Stronger Our Message
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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.
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The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.
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