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Medicare Vows to Fix Drug Program

Posted on: Tuesday, 17 January 2006, 09:01 CST

By Kevin Freking

Tens of thousands of elderly poor people may have had trouble getting their medicine during the first two weeks of the government's new Medicare prescription drug benefit, and about 20 states including New York have been forced to step in to help them, the top Medicare official has acknowledged.

The problems will be fixed, said Mark McClellan, administrator for the Centers for Medicare and Medicaid Services, on Friday. In some cases, people are not showing up in databases as being enrolled in a health care plan. When they do show up, many people are being told they need to pay hundreds of dollars before they can get their medicine. Instead, they should owe only nominal amounts.

"I'm working with the states, with the plans, with all of our partners to make sure people get the prescriptions they need," McClellan said.

Under the program, about 42 million disabled and older people are eligible to enroll in private health care plans that will subsidize their prescription drug costs. Millions of prescriptions have been filled without trouble, McClellan said, but there is growing concern that some of the poorest beneficiaries who qualify for both Medicare and Medicaid -- so-called dual eligibles -- cannot get their medicine.

Some advocacy groups say they believe that McClellan underestimated the problems. "We could see the problems coming. We expressed concern, and it was just pooh-poohed. Now, our worst fears have been realized," said Jeanne Finberg, a lawyer with the National Senior Citizens Law Center, which is based in Oakland, Calif.

The problems go beyond technical difficulties, such as computer databases failing to note that a beneficiary is enrolled in a plan. In some cases, private plans are just not following guidelines established for their participation in the program.

The plans are not issuing emergency drug supplies as required, and they have set up prohibited restrictions on the types of medicine that beneficiaries can get during the first weeks of the program, according to the American Psychiatric Association.

"Relapse, re-hospitalization and disruption of essential treatment are some of the consequences of the bureaucratic nightmare," said the association's president, Steven S. Sharfstein.

McClellan said he has directed plans providing drug coverage under the program to make it easier for pharmacists to resolve questions about beneficiaries.

"I've been in touch with the health plans today, and they are setting up expedited processes for pharmacists to contact a plan without waiting in a long queue. The plans are setting up those systems right now," he said.

McClellan said health care plans were required to provide a 30- day supply of drugs, even if their plan does not cover a particular drug. In cases where a drug is not on their list of approved drugs, plans require pharmacists to get pre-authorization before dispensing the drug. Many plans are waiving the pre-authorization requirement, McClellan said.

The agency also updated information on Friday so that pharmacists can more quickly reach health care plans, McClellan said.

He also said he contacted several governors and the staff of the National Governors Association last week on how best to help dual eligible beneficiaries.

Some lawmakers have demanded that the federal government reimburse states for those efforts, but McClellan said the insurers and other businesses offering coverage would do that.

"The plans are getting paid additional amounts to provide the extra coverage for the dual eligible beneficiaries. It's a matter of reconciliation," he said. "If the state works with us . . . we can send that information onto the plan so the plan reimburses the state."

McClellan said Medicare has caseworkers on hand for beneficiaries or pharmacists with questions about the new benefit. They can call 1- 800-Medicare for help.

Source: Buffalo News

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