Lisa Hoffman and Charles Atkins

Published September 22, 2005

Just as we prepared for the year 2000 and billions of dollars were spent around a potentially catastrophic computer glitch, another big issue is coming fast and furious for half a million CT residents. Come January 1, 2006 the Medicare Prescription Drug plan a.k.a. Medicare D goes into effect. If you, or someone you care about, are a Medicare recipient, and if you haven’t already begun, it’s time to get educated. And just like the year 2K computer conversion, it’s unclear how smoothly the transition to Medicare D will go. In the words of my inner Boy Scout, "Be Prepared".

Let’s start with a lightening quick overview of the Medicare system. Overseen by the federal government, both Medicare and Medicaid (which, in Connecticut, is 50% state and 50% federally funded) came about in the 1960’s to provide health coverage to older Americans and the disabled (Medicare) and the very poor (Medicaid). Medicare, up until now has had two major components A and B. While there are exceptions Medicare A covers inpatient hospital expenses, home health services, and nursing home/rehab while Medicare B is for outpatient and professional services, durable medical equipment and home health services. Medicare C, which is not a big player in CT at the moment, is the Medicare Advantage Program that offers options for financing healthcare including HMOs, Health Savings Accounts and Private Fee-for-Service Plans. More of these Medicare Advantage plans are expected in Connecticut in 2006. Medicare D—our focus today--is part of the Medicare Modernization Act that was passed in 2003. As a political sound bite, Medicare D is an attempt to provide some coverage of prescriptions drugs under the Medicare benefit. It’s a confusing piece of legislation with different sets of answers for different groups of Medicare beneficiaries, and as the January 1^st go-live date looms, if you find yourself confused count yourself in the majority.

To assist in our education, and to try for a bit of clarity, Lisa has enlisted the aide of paralegal Rebecca Ganci from the Center for Medicare Advocacy. We’ve prepped for the interview and have both been through several brochures and articles on the topic. The trouble I find is that the more I read about this, the more questions I have including some serious concerns that we’ll get to. So with the lime-green carpet of Lisa’s condo strewn with articles, we place the call.

Rebecca is waiting and Lisa wastes no time putting her on speaker phone and launching in, "Could you start by giving us a sense of what the Center for Medicare Advocacy is and does?"

"We are a non profit and non partisan organization," she begins, "that provides education, advocacy and legal assistance for elders and people with disabilities to help them obtain necessary healthcare. We focus on the needs of: Medicare beneficiaries, people with chronic conditions and those in need of chronic care. We’ve been in existence since 1986 and are funded by a variety of grants and projects, as well as having contracts with the state of CT."

"How about other states?" Lisa asks.

"The organization is involved in policy work and litigation of national significance. The Center’s headquarters are in CT but we also have offices in Washington DC and Maine.

"We have an extensive website at www.medicareadvocacy.org. In addition, we recently developed a new website specifically about Medicare Part D and its impact in Connecticut," she continues, "partnering with the CT State Health insurance program, which is called CHOICES and has 5 area Agencies on Aging throughout the state. You can access the CHOICES site by going to www.medicareadvocacy.org and clicking on the top right button. Next, click the button for Medicare D, which brings you to a section that answers frequently asked questions. There’s even an optional quiz where you can test your knowledge."

"So what are some of the most asked questions?" Lisa asks.

"We get a lot of questions about how employer plans will coordinate with Part D, We have questions regarding people who have both Medicare and Medicaid, the so-called dually eligible people (At this point my ears perk as the dually eligible include many people with serious and persistent mental illnesses and medical illnesses. It’s sometimes easy to forget that Medicare is not just for older people, but also for those with disabilities. As we’ll see there are some serious issues with Medicare D that will impact these individuals). Rebecca continues, "We get questions regarding the Prescription Drug plan formularies and what constitutes "creditable coverage", a term that relates to whether the coverage an individual already has is considered equal to Part D. Individuals who do not have creditable coverage will have to pay a higher premium if they don’t sign up for Medicare D between November 15^{th 2005} and May 15^th 2006, or when they are first eligible."

"These are great questions," I comment, while typing fast and realizing that we’ll need to break this up into two columns. "Let’s start, by taking a person who has Medicare A and B, what are the most-important points for them?"

"They need to think about enrolling in a Prescription Drug Plan (PDP) between November 15^th 2005 and May 15, 2006."

Lisa asks, "What happens if you don’t enroll?"

"Part D is optional and some may choose not to enroll. But that choice may have consequences. For instance, if you’re in a situation where you don’t have any prescriptions it might not make sense to pay the $32.20 per month premium, not to mention the $250 annual deductible. So if you weigh that against a one-percent-per-month penalty if you enroll later on; it’s really a personal choice. But the factors to consider with each plan you look at also have to do with what’s on the plan’s formulary i.e. the drugs covered by that company. Does the formulary include the medications you need?"

Lisa perks up. "I have a question, for instance I am on ConnPace and among the drugs I use is Coumadin, but I cannot use the generic because I’m allergic to it. So each time I need it refilled the doctor has to write to the pharmacist. Will this be a problem?"

"For those who don’t know," Rebecca explains, "ConnPace is CT’s State Pharmaceutical Assistance Program (SPAP). ConnPace helps eligible CT citizens—over 40,000 of them--pay for prescription drugs. To qualify you need to be a CT resident, be either 65 or older or disabled, and effective January 1, 2005 have an income under $21,400 for an individual or $28,900 for a married couple and you can’t have any other medication coverage. Beginning in 2006, a new requirement for ConnPace is that you must sign up for Medicare D. Getting back to your Coumadin question, if your Prescription Drug Plan does not have it on the formulary there’s an appeal, known as the Exceptions process."

As a doctor listening to this, phrases about notes to pharmacists, appeals and exceptions processes fill me with dread. For busy physicians with many Medicare patients--who will now be enrolled in many different drug plans (18 at last count)--what’s the impact going to be?

"As folks get older," I comment, "it’s not uncommon for them to be on multiple medications. Lisa has at least six. How will people figure out if all of their medications are covered under a particular formulary? My understanding is that these Drug Plans only have to offer two drugs from any given class of medication with the exception of medications for mental illnesses, cancer and HIV/AIDs. I also understand that some medications, such as the Valium family (benzodiazepines) and some of the older anticonvulsants (barbiturates) won’t be covered at all."

"Well, there is a web tool that will be available starting in October for people acclimated to the Internet, where they can enter their medications to see which plans will cover them. They can also call 1-800-medicare. The site is www.ssa.gov. There is also information on Part D available at www.medicare.gov and cms.gov."

"So to start," I say, "if people haven’t already begun to do this it seems the best thing right now is to get some education around Medicare D, hopefully this column and the next (where we’ll go into specifics around eligibility and full and partial subsidies) will help, but folks might want to contact their local senior center or Agency on Aging for times and locations of Medicare D trainings. I also think it’s critically important that healthcare workers take the time to read up on Medicare D, go to a training or two, and help their patients through the process."

Just as we prepared for the millennium, Medicare D is coming, the clock is ticking down and while we hope for the best and that the transition will be a smooth one, we can’t count on it. Fore warned is fore armed, and like my inner Boy Scout, we need to be prepared.

The Center for Medicare Advocacy

800-262-4414 and (860) 456-7790 phone

860-456-2614 fax

www.medicareadvocacy.org website

Medicare

800-MEDICARE

www.medicare.gov website

National Alliance for the Mentally Ill

www.nami.org web site (the Medicare D section is under the link for Public Policy)

1-800-950-NAMI their help line

The Social Security Administration

www.ssa.gov web site