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Medicare Pressured on Drug Coverage for Dual
Eligibles, Nursing Home Patients
One lawsuit and a letter to Congress this week
highlights major concerns
Nov. 19, 2005 – Medicare was getting pressure from
two fronts this week to assure drug coverage for the poorest of senior citizens – the “dual eligibles” covered by Medicare and Medicaid,
and those who reside in nursing homes.
The most dramatic move was a lawsuit filed by eight
advocacy groups in federal district court in Manhattan seeking an order
assuring that people do not lose access to “life-preserving medication”
on January 1, when the new Medicare Part D prescription drug plan
begins.
In the second action, the Long Term Care Pharmacy
Alliance (LTCPA), sent a letter to the President and Congress urging a
change in Medicare rules that currently prevent nursing home staff and
pharmacists from counseling seniors about which of dozens of Medicare
drug plans best serve their needs.
They said their action is “a response to reports of
wide-spread confusion among seniors seeking help enrolling in the new
Medicare prescription drug plan,”
The lawsuit by the advocacy groups seeks
protections for people who are not “seamlessly and immediately
transitioned” to the Medicare drug program.
Under Bush Administration plans, the 6.4 million
people enrolled in both Medicare and Medicaid – “dual eligibles - will
no longer receive their drugs through Medicaid, but will be
automatically switched to a new Medicare drug plan. Medicare is then
required to provide coverage to these beneficiaries under the 2003
Medicare Modernization Act.
Medicare has repeatedly said they are prepared for
the transition and all dual eligibles will be receive their drugs. They
released a detailed plan this month for how this transition will occur
(see sidebar link to story).
“The poorest, sickest, and oldest Americans face
grave risk of losing their life-saving medications once the clock
strikes twelve on New Year’s,” said Robert M. Hayes, president of the
Medicare Rights Center, a national consumer service group. “This lawsuit
seeks to force creation of an essential safety net to protect the health
and lives of the frailest Americans.”
The suit warns that “countless” numbers of poor men
and women “will fall through the cracks of this massive program
transition,” and that these impoverished people will face the loss of
medicines needed “to function or survive.”
It also says that the characteristics of the people
at risk – nearly 40 percent are cognitively impaired and only 39 percent
have a high school diploma—will prevent up to a million poor seniors
from immediately mastering the complexity of the new Medicare drug
benefit so they can maintain their access to needed medicine.
To be eligible for Medicare, one must be severely
disabled or age 65 or over. To be eligible for Medicaid, most states
require that people have incomes well below the poverty level and have
virtually no assets. About 43 million Americans are enrolled in
Medicare, and about 6.4 million of them are also enrolled in Medicaid.
Among the organizations who have filed the suit
are:
● Action Alliance of
Senior Citizens of Greater Philadelphia,
● Congress of
California Seniors,
● Massachusetts
Senior Action Council,
● National Alliance
for the Mentally Ill: Maine,
● New York
Statewide Senior Action Council,
● The Coalition of
Voluntary Mental Health Agencies, Inc.,
● United Senior
Action of Indiana, and
● the Medicare
Rights Center of New York.
The organizations are being represented by
volunteer attorneys with the law firm Paul, Weiss, Rifkind, Wharton &
Garrison LLP, and the Medicare Rights Center.
“Protecting the oldest, poorest and sickest
Americans through this transition is a legal and moral imperative,”
Hayes said. “If the government transitions 99 percent of these men and
women flawlessly, there will still be 64,000 people without their
medicine come January. That cannot be allowed.”
A copy of the complaint filed in federal district
court in Manhattan today is available at
http://www.medicarerights.org/complaint.pdf; also online is the
Medicare Rights Center’s report
Protecting the Poorest Americans During the Medicare Drug Transition.
Nursing Home Complaint
The LTCPA’s complaint about those who reside in
nursing homes says that under current regulatory guidelines issued by
the Center for Medicare & Medicaid Services (CMS), which administers the
new drug plan, nursing home staff and pharmacists are not allowed to
help seniors choose the best drug plan for their needs.
Instead, the rules direct nursing home care givers
and pharmacists to refer seniors and their families to a CMS internet
plan finder or a toll free phone number to find information about plans.
“We very much want to the new prescription drug
plan to be successful in serving nursing home residents,” said LTCA
executive Director Paul Baldwin. “Unfortunately, current regulations
prevent seniors from receiving help from the very care providers who are
responsible for their well-being. That needs to change. Care providers
want to help and they should be allowed to help. Simply telling them to
point frail elderly nursing home residents to a computer keypad or a
telephone is not good enough.”
A typical nursing home resident is 84 years of age,
suffers from eight different diseases and is on nine medications at any
given time. Over half of all nursing home residents have some level of
cognitive impairment.
“The Bush administration recognized the special
circumstances of seniors in nursing homes when they gave them the option
to change drug plans monthly as their medical needs change. Now we need
to change the rules so seniors can get help in choosing the right plan,”
Baldwin added.
They say a Kaiser Family Foundation survey released
this past week shows 76% percent of seniors have never surfed the web,
and only 8% of seniors have ever called the 1-800-MEDICARE phone
number. Those options are even less helpful for nursing home
residents, a majority of whom are cognitively impaired and in frail
health. The same survey also found 75% of seniors expect their
pharmacist to be knowledgeable about the plans.
The stakes for nursing home residents are
especially high, even for those Medicaid-eligible seniors who will be
automatically and randomly assigned one of perhaps dozens of plans by
CMS. Beyond the basic information about drugs covered and plan costs,
plan details which restrict or delay immediate access to drugs can have
serious health implications, and that information may be even more
difficult nursing home residents to discern online.
“The plans are hard enough to figure out for a
65-year-old with a college degree and a computer at home,” Richard
Mollet, executive director of the Long Term Care Community Coalition
recently told the Orlando Sentinel. “There are a lot of frail,
impoverished people in nursing homes who are going to fall through the
cracks and suffer and die because of it.”
The Long Term Care Pharmacy Alliance represents
providers of long-term care pharmacy services to residents of nursing
homes and other long-term care facilities. Find out more at
www.ltcpa.org
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