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State Offers Medicare Advice to Help Low-Income Residents Get Prescriptions

Posted on: Wednesday, 18 January 2006, 21:00 CST

By Pittsburgh Post-Gazette

Jan. 17--With Pennsylvania Medicaid recipients still struggling to obtain their new Medicare prescription drug benefits, officials said yesterday that the state would expand efforts to help low-income residents get their medications.

Gov. Ed Rendell announced that Pennsylvania will cover the cost for a five-day supply of medicines for Medicaid recipients who experience troubles at pharmacies because their drug benefits were switched to Medicare on Jan. 1.

With the new effort, the state is prepared to spend up to $10 million to help Medicaid recipients who are caught in a variety of glitches in the new federal program, and possibly going home without medication as a result.

Just last week, Pennsylvania joined more than 10 states that have taken steps to ensure that Medicaid patients can continue to receive their medications. But state officials said yesterday that the earlier effort, which involved spending as much as $2 million to cover the cost of high co-pays unfairly charged to some patients, was not enough to resolve the range of problems people are experiencing.

"The good news is, the Rendell administration is clearly being responsive," said Alissa Halperin, managing attorney for the Philadelphia office of the Pennsylvania Health Law Project, whose group has kept the state informed about consumer problems. While providing five days of coverage "has the potential to help a lot of people," Ms. Halperin questioned whether it was long enough.

Jim Hardy, acting deputy secretary for the state's Medical Assistance program, added that the state will pay for a second five-day supply for Medicaid consumers, when necessary.

Kate Philips, a spokeswoman for the governor, said the state might consider further action if things aren't better in a week.

Still, the hope is that providing five days of medication, beginning today, will allow enough time for the federal government and health plans to iron out the wrinkles, Ms. Philips said.

About 6.4 million Medicaid recipients in the United States, including more than 250,000 in Pennsylvania, had their benefits switched to the new Medicare prescription drug program, starting this year. The government acknowledged last week that several hundred thousand of these people were experiencing problems while trying to fill prescriptions.

Federal officials said most of the problems involved Medicaid recipients who opted out of automatic assignments into new Medicare drug plans, and instead selected plans that better met their needs. As a result of computer problems, health plans for these consumers didn't know that patients should be charged co-pays of $1, $3 or $5, rather than higher co-pays or $250 deductibles.

But state officials said the co-pay problems in Pennsylvania were not limited to people who opted out of automatic assignments, but instead seemed to involve a wider set of Medicaid recipients. What's more, of all the problems being experienced by Medicaid recipients in the state, only about 20 percent primarily involved co-pays.

Whereas the co-pay program announced last week helped about 100 people during the weekend, the new program should address two broader problems, said Mr. Hardy.

In one scenario, Medicaid consumers who lack cards from their new drug plans are finding that pharmacists can't determine which plan should pay their claims. While the federal government has a backup system to help in such situations, it apparently isn't working in all cases, Mr. Hardy said, so pharmacists can now bill Pennsylvania Medicaid.

In another scenario, consumers know their Medicare plan, but find that their medications aren't on plan formularies or require prior authorization before they can be dispensed. While the federal government is working with health plans to make sure consumers in this situation still get their drugs through transition plans, the state will serve as the ultimate backup.

Last week, state officials said they were reluctant to pay all drug costs for Medicaid patients caught in Medicare glitches for fear that doing so would let the federal government off the hook.

What's more, Pennsylvania was concerned that it might not be reimbursed for its costs.

Federal officials say they can't directly reimburse states for their backup pharmacy systems because Medicare has already paid health plans to provide the medications.

This week, Mr. Hardy said he was "cautiously optimistic" that, one way or another, the state would be re-paid, adding that the expanded effort will help more people.

"I think the governor heard from a lot of consumers that, while they appreciated what we were doing on the co-pays and while [the federal government] has been communicating that things are getting better, there was still a lot of concern that it was going to take time for the system to work right," Mr. Hardy said.

By Christopher Snowbeck and Joe Fahy

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Source: Pittsburgh Post-Gazette

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