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As Medicare Tangles, State Guarantees Prescriptions

Posted on: Tuesday, 10 January 2006, 15:00 CST

By Jeffrey Krasner, The Boston Globe

Jan. 10--State health officials yesterday ordered pharmacists to fill prescriptions under the new Medicare drug plan after learning that some senior citizens are being denied their medications.

The emergency action was taken after federal Medicare officials spoke with state officials about similar measures taken by other states -- including Connecticut, Maine, New Hampshire, and Vermont -- since the benefit went into effect Jan 1. Some seniors have been unable to get prescriptions filled because pharmacists cannot confirm their new insurance coverage.

"We didn't want to wait any longer," said state Medicaid director Beth Waldman. "We wanted to make sure folks weren't walking away from the pharmacies without their medication."

The move, which will cost the state between $1.5 and $2 million a day, ensures three groups will receive prescriptions immediately: low-income seniors, disabled people on Medicaid, and those receiving benefits under the state's Prescription Advantage drug subsidy program. About 262,000 Massachusetts residents who should be covered under the Medicare program are affected. Pharmacists have been instructed to fill their prescriptions and bill the state.

The state will try to collect the money from the individual insurance companies that provide Medicare coverage. But there is no assurance from the federal government that the state will be able to recover all of the money.

"If this continues all year, the money will become an issue," said Waldman, who heads MassHealth, the state Medicaid program. "If it's just a couple of weeks, the money won't be a problem."

Since Jan. 1, there have been dozens of reports of seniors being turned away from pharmacies without receiving prescription drugs. Seniors who have signed up for prescription insurance plans under the new federal benefit are supposed to receive a card or a letter verifying their coverage. When they cannot produce such documentation, pharmacists contact Medicare or individual drug plans to confirm coverage.

But phone lines have been jammed and computer search tools have been unreliable. That has put pharmacists in the position of either filling costly prescriptions without knowing whether they will receive payment or refusing to fill prescriptions for which coverage cannot be verified.

Even seniors with proof of coverage have encountered problems when pharmacists find their new drug plan does not cover their specific medications.

The Medicare plan is "imploding," said Chris Venier, owner of Theatre Pharmacy in Lexington. "It's a disaster. Last Friday, one company help line said they couldn't process the call and instructed me to hang up. Then, the help line was closed for the weekend. Medicare is not getting the job done right."

The benefit, known as Part D, provides prescription drug coverage to seniors for the first time since Medicare began in 1965. The federal government has urged seniors who do not have drug coverage through a union or former employer to sign up for the benefit. But advocates for seniors and a host of critics have long warned that the plan is too complicated and would lead to disruption in medication.

For months, the focus was on helping seniors choose from dozens of competing drug plans. Drug companies and government agencies spent tens of millions of dollars on educational programs to make the benefit understandable.

Medicare advocates said they're not surprised that emergency action was needed because the plan is so unwieldy.

"For months everyone knew this was going to happen," said Bob Hayes, executive director of the Medicare Rights Center, a nonprofit group in New York. "There has been an ostrich-like reaction to reality in this administration. Right now, there's no state where people are not at dire risk."

The state's action drew praise from healthcare advocates who have watched the problems unfold during the past week.

"MassHealth has done a fabulous job responding to this problem," said Melissa Shannon, consumer health policy coordinator at Health Care for All, a state advocacy group. "It's been a mess and they stepped up because there was no other way to ensure that people weren't turned away at the pharmacy."

State Senator Mark Montigny, a Democrat from New Bedford, said a bill he sponsored that was signed into law the last week in December already guaranteed that pharmacists will be paid if they provide drugs on an emergency basis to residents whose new drug plans don't cover specific medications.

"Every pharmacist should know that all the drugs are covered and we'll worry about who pays for it later," Montigny said. "It shouldn't have taken a week to figure that out. The law is very clear."

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Source: The Boston Globe

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