CMS rule on Rx drugs lambasted

Consumer advocates say the Bush administration’s proposed Medicare rules would leave the poorest senior citizens without prescription-drug coverage for nearly six months.

At issue is the status of so-called dual eligibles, the more than 6 million Medicare beneficiaries with full Medicaid coverage. Under the Centers for Medicare and Medicaid Services (CMS) proposed rules to implement the drug benefit, these dual eligibles could face a gap in drug coverage.

Dual eligibles will be automatically enrolled in the Medicare drug benefit beginning May 15, 2006, but their Medicaid drug benefits will expire Jan. 1, 2006. In comments on the proposed regulations, a coalition of beneficiary advocacy groups, the Medicare Consumers Working Group, said the rules do not address the problem in a way “that will ensure that these 6.4 million beneficiaries do not confront a loss of benefits or a gap in drug coverage, either of which could have disastrous health consequences for these individuals.”
Consumer advocates say the Bush administration’s proposed Medicare rules would leave the poorest senior citizens without prescription-drug coverage for nearly six months.

At issue is the status of so-called dual eligibles, the more than 6 million Medicare beneficiaries with full Medicaid coverage. Under the Centers for Medicare and Medicaid Services (CMS) proposed rules to implement the drug benefit, these dual eligibles could face a gap in drug coverage.

Dual eligibles will be automatically enrolled in the Medicare drug benefit beginning May 15, 2006, but their Medicaid drug benefits will expire Jan. 1, 2006. In comments on the proposed regulations, a coalition of beneficiary advocacy groups, the Medicare Consumers Working Group, said the rules do not address the problem in a way “that will ensure that these 6.4 million beneficiaries do not confront a loss of benefits or a gap in drug coverage, either of which could have disastrous health consequences for these individuals.”
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Centers for Medicare and Medicaid Services Mark McClellan, right, with Health and Human Services Secretary Tommy Thompson

A CMS spokesperson said the agency is “aware of the gap” and is working with the states and the Social Security Administration to identify and notify dual eligibles that they qualify for a prescription-drug subsidy. CMS intends to ensure that there is no gap in the final rule, the spokesperson added.

The coalition consists of several prominent advocacy groups, including the National Committee to Preserve Social Security and Medicare, the Center for Medicare Advocacy and Families USA.

Dual eligibles could enroll in a plan before the end of 2005 to avoid a coverage gap, but Marc Steinberg, a Families USA health-policy analyst, said it would take a massive outreach and education program to make sure most dual eligibles are aware of this option. In addition, dual eligibles, who often have severe illnesses, are “a very challenging population to reach,” Steinberg said.

A coverage gap for dual eligibles would increase taxpayer costs because some beneficiaries would likely need costlier services, such as hospital stays or crisis interventions, the coalition said.

Judith Stein, executive director of the Center for Medicare Advocacy, said she is “aghast at how unworkable Medicare will be should the Medicare Modernization Act (MMA) be implemented.”

Stein said those beneficiaries who could lose coverage “are the poorest and sickest of all Medicare beneficiaries.” Indicating that the drug benefit would help private insurers more than seniors, Stein added, “Americans need to scrap this law, stop the pretense that MMA creates a fair, realistic prescription-drug program, and start fresh.”

AARP, the powerful consumer advocacy group, also alerted CMS to the problem facing dual eligibles in its separate comments. “Leaving dual eligibles without drug coverage for any time during their transition from Medicaid to a Medicare drug benefit is clearly not an option.”

AARP said auto-enrollment of dual eligibles should occur by the end of 2005.

The consumer-advocacy coalition also said the proposed rules might leave dual eligibles without the opportunity to pick the prescription-drug plan they would need most, which would especially burden those with life-threatening diseases, such as HIV/AIDS or cancer.

The rules propose that dual eligibles enroll in average-cost plans in their regions, which could leave them with less drug coverage than they currently have under Medicaid.

The consumer advocates say CMS must honor the promises that Congress and the administration have made to dual eligibles, specifically that they would be better off under the new drug benefit.

AARP also said beneficiaries expressed concern over a provision that locks them into a certain plan while allowing the provider of that plan to change the benefits.

Stating that this is the same concern that was a reason for lower enrollment in the prescription drug discount card plan, AARP urges CMS to address the issue.

The consumer advocacy coalition and AARP also have strong concerns regarding the clarity of the regulations. Steinberg said the Medicare drug benefit is “extremely complicated legislation,” adding that CMS has given implementing it “a reasonable shot … but left a lot of uncertainties in the rules.”

AARP urged CMS to ensure that beneficiaries receive information on drug plans in “plain language” to be able to make informed choices. The group also advocates making information available in other languages. AARP strongly presses CMS to prohibit plan sponsors from marketing services and products unrelated to the drug benefit to beneficiaries in order to nor “muddy the water.”

Saying that the “sheer size and complexity of these regulations is also a testament to the fact that this new law is terribly confusing to most Medicare beneficiaries,” the Medicare Consumers Working Group asked CMS to simplify the program, adding, “In most cases, simplification will be the pro-consumer position.”

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