WASHINGTON—Some of the nation's oldest, sickest and poorest people could find themselves without drug coverage on New Year's Day if their transition into the new Medicare prescription drug benefit doesn't go smoothly.
Medicare officials, knowing that even a short coverage lapse for any of these roughly 6.4 million people could be life threatening, have automatically enrolled them in the new drug plan to assure that their drug regimens are uninterrupted.
But lawmakers, advocacy groups and now a congressional watchdog agency say that may not be enough. They say that untold numbers of these so-called "dual eligibles"—who receive benefits from both Medicare and Medicaid—will still fall through the cracks when their drug coverage shifts from Medicaid to Medicare on Jan. 1, 2006. Medicare is the federal health program for elderly and disabled people, and Medicaid is the state and federal health program for the poor.
"We're certainly concerned," said Christine Bronson, the Medicaid director in Minnesota, where 93,000 dual-eligible beneficiaries reside. "Whenever you make a change this big, perfection is not a realistic expectation."
Some will miss out on the new coverage due to inaccurate enrollment lists, administrative errors and their own confusion about the benefit. Others worry that these clients could be assigned to new plans that won't let them fill prescriptions at their regular pharmacies or cover all their medications.
Preliminary findings from a pending report by the Government Accountability Office say those kinds of "problems will likely arise" because of the complex nature of the Medicaid-to-Medicare shift, which affects all dual beneficiaries at once and provides no transition period or overlap in their coverage.
The draft GAO report concludes that Medicare's "plans are not adequate to ensure, that in all cases, dual-eligible beneficiaries can immediately obtain necessary drugs." That could pose serious problems because they have higher rates of chronic illness, disability, cognitive impairments and other health needs.
Last week, eight consumer-advocacy groups sued the federal government seeking stronger safeguards to assure that dual beneficiaries get uninterrupted coverage.
"(Medicare) says it has a `fail-safe mechanism' to guarantee that dual-eligibles do not lose access to their medicines. But after learning of GAO's findings, I am not convinced," said Sen. Max Baucus, D-Mont., who requested the GAO study.
Consider Barbara Hunt, a dual-eligible beneficiary from Hamden, Conn., who uses a wheelchair and takes 15 different medications each day for pain, fibroids, asthma, osteoporosis, high cholesterol and other ailments.
Hunt, 58, doesn't know if she's been enrolled in a plan and worries that none will cover all her medications. Because of her fixed, monthly $719 income from Social Security Disability Insurance, she can't afford to pay full price for drugs that aren't covered. The $1 to $3 co-pays required under the Medicare coverage will also hurt, she said.
"I am terrified," she said. "It seems on the surface that wouldn't be a hardship, but if you have to pay that every single time you go to the drugstore, that's a lot of money." When her coverage was under Medicaid, all of Hunt's prescription drug costs were covered.
Medicare officials stress that the GAO study is incomplete and that the final version will better reflect the safeguards in place to avoid coverage lapses, said Gary Karr, a Medicare spokesman. Private contractors are checking enrollment data to ensure that no people will go without coverage.
For people that may be overlooked, "we're working on a mechanism where we can capture that person and make sure they can walk out of the pharmacy with their prescriptions and the billing issues will be taken care of" later, Karr said.
But some fear that people who become dually eligible late in 2005 could face a one- to two-month wait for coverage. That's because of a time lag between submission to Medicare of monthly state eligibility lists and the time that drug coverage actually takes effect.
"That will certainly be a challenge," said Bronson, the Minnesota Medicaid director. "(Medicare) said they'll try to have some mechanisms in place to bridge those days or weeks, but it's unclear how that will play out for an actual individual."
Any glitches could expose an already vulnerable population to additional hardships. Dual-eligible beneficiaries are disproportionately minorities and women. Many are likely to have poor educations, live alone and have more than two chronic illnesses. They're also more likely to be at least 85 years old. About 23 percent of dual enrollees are in nursing homes, compared with roughly 3 percent of other Medicare recipients.
They're also expensive. In 2000, they made up 18 percent of Medicare beneficiaries, but accounted for 24 percent of Medicare spending, the GAO reports. In 2003, they accounted for 14 percent of Medicaid enrollees, but 40 percent of spending—mostly on prescription drugs.
Drug coverage for duals under Medicare will be generous. They'll pay no premiums or monthly deductibles and their co-payments will range from $1 to $5, depending on the medication and their income level. In all, roughly 98 percent of their drug costs will be paid.
In the summer, Medicare sent letters informing duals about their drug coverage change from Medicaid to Medicare. In October, they were automatically assigned to a Medicare drug plan and mailed notices. Between Nov. 15 and Dec. 31, they can opt out of their assigned plan and select another that better suits their needs.
If they don't do so by Dec. 31, they'll remain in their assigned plans. Unlike other Medicare drug plan enrollees who can switch drug plans only once a year, duals can do so each month to ensure access to needed drugs.
But because of their frail conditions, many duals won't be able to navigate the complex individual choices and machinations needed to maintain optimal coverage, advocates say.
Elsie Williams, a dual beneficiary in Paradise, Calif., just outside Sacramento, was assigned to a plan, but hasn't been able to reach its phone operators to see if all of her eight medications are covered. Frustrated, she called 1-800-Medicare for help. But she said she was incorrectly told to go to her Social Security office for assistance.
"I've got some gray hairs over this," said Williams, 68. "It has really frustrated me. I used to be able to go and get all my prescriptions (under Medicaid) and not worry about a co-payment or anything else. Then all of a sudden, this gets slammed on us, and we're the underdogs. What are we supposed to do?"
For a list of state counselors who can help select a Medicare drug plan, go to www.healthassistancepartnership.org and click on "Medicare" in the lefthand column. Then click on "State Health Insurance Programs."
(c) 2005, Knight Ridder/Tribune Information Services.
GRAPHIC (from KRT Graphics, 202-383-6064): 20051118 BENEFITS
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