Part D Plans Generally Cover Drugs Commonly Used By Dual Eligibles-DHHS OIG

Download the complete report (PDF)
Adobe Acrobat Reader is required to view PDF files. Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

This report was mandated in the Patient Protection and Affordable Care Act of 2010.

Dual eligibles are individuals who are eligible for both Medicare and Medicaid. Overall, we found that the rate of Part D plan formularies' inclusion of the 191 drugs commonly used by dual eligibles is high, with some variation. On average, Part D plan formularies include 96 percent of the 191 commonly used drugs. In fact, 90 percent of dual eligibles are enrolled in Part D plans that use formularies that include at least 90 percent of the commonly used drugs.

Dual eligibles are a particularly vulnerable population. Overall, they are in worse health than the average Medicare beneficiary and typically require and use more prescription drugs, and more health care services in general, than other Medicare beneficiaries.

To control costs and ensure the safe use of drugs, Part D plans are allowed to establish formularies from which they may omit drugs from prescription coverage and control drug utilization through utilization management tools. These tools include prior authorization, quantity limits, and step therapy. CMS annually reviews Part D plan formularies. CMS also assesses the utilization management tools present in each formulary.

We found variation in the rate at which Part D plan formularies apply utilization management tools to the drugs commonly used by dual eligibles. Some Part D plan formularies apply these tools to none of the commonly used drugs, whereas others apply these tools to 45 percent of the commonly used drugs.

We make no recommendations in this memorandum report. However, we have provided CMS the list of 200 drugs commonly used by dual eligibles for its reference.

Fundamental Changes To Medicare Proposed By Elder Law Expert

House Budget Committee Chairman Paul Ryan's proposal to change Medicare for those under age 55 is nothing short of a complete reconceptualization of the health insurance program, says a University of Illinois elder law expert.

Richard L. Kaplan, a professor of law and expert on retirement issues, says the Ryan proposal would scrap Medicare's current defined-benefit program in favor of a defined-contribution arrangement in which the government would provide seniors with a stipulated amount of money to purchase health insurance from private insurers.

"The Ryan proposal would eliminate the package of benefits that everyone receives but would allow seniors to choose from a variety of plans with different benefits, different premiums and different co-payment obligations," Kaplan said.

Kaplan, the Peer and Sarah Pedersen Professor of Law at Illinois, says that what Rep. Ryan is proposing isn't a radically new idea, as a broadly similar plan was first considered at length during the Clinton administration.

"It was proposed under the title of 'premium support,' though occasionally it has been described as vouchers," he said. "Essentially, it's the same concept - provide seniors with a designated amount of money and let them shop for the plan that best meets their needs."

While there may be nothing new under the sun in Washington, that doesn't mean that some seniors won't come out ahead under the Ryan proposal.

"Some seniors will benefit, because they will be able to use their Medicare dollars for benefits that they prefer," Kaplan said. "For example, Medicare currently pays for individual hospital stays of 60 to 90 days in length. But the average hospital stay for someone 65 years and older is less than six days. So a prospective Medicare enrollee might choose a plan in the proposed system that provides shorter hospital stay coverage but more extensive home health care coverage than Medicare currently includes."

The chief motivator of the Ryan plan is to, plain and simple, save the government money, Kaplan said.

"As medical costs increase, Medicare's costs rise accordingly," he said. "Under the Ryan plan, Medicare's costs would be fixed and known in advance. Increases in medical costs over whatever cost-of-living increase the government dictates for Medicare will not be borne by Medicare, but by those seniors who choose more comprehensive benefit plans."

Although last year's health care reform law left the basic structure of Medicare intact, the Ryan proposal would transform Medicare to make it resemble the types of health insurance plans that many employers offer to their employees. Although this would represent a dramatic change, Kaplan said, such changes to Medicare are not wholly unprecedented.

"Actually, Medicare Part D, which provides coverage for prescription drugs, operates on a very similar basis - private insurers receive government subsidies to provide various drug plans, and seniors select among the options that are available, paying more for greater coverage," Kaplan said.

But in a different health insurance paradigm, the downside is that seniors will almost certainly face more complexity.

"If our experience with Medicare Part D's drug plans is any indication, older Americans will confront a new array of insurance plans under Medicare, some of which may change their components annually," Kaplan said.

But Kaplan is quick to note that the present system is no walk in the park either.

"Presently, most seniors sign up for hospital coverage under Medicare Part A, then decide whether they want to purchase Medicare Part B coverage for physicians' charges, and then decide whether to add a Medicare Part D plan to cover their prescription medication needs," he said. " Then they must consider whether to buy a private Medigap insurance plan to pay for the deductibles and co-payment or co-insurance obligations of Medicare Parts A and B. So, in many ways, the new system of integrated benefit plans will be simpler and more intuitive. But the transition to this new environment will certainly be challenging."

Not all seniors will be affected by the change; adults 55 years and older would be largely unaffected by Ryan's proposal, Kaplan said.

"Unless an option is provided to let them switch, which may or may not be incorporated into the final plan, anyone who is in Medicare presently will not be affected by his proposal," Kaplan said. "Those seniors who are already familiar with Medicare's component parts need not bother with this legislation."

Source:
Phil Ciciora
University of Illinois at Urbana-Champaign

Medicare Rights Center's Health Reform & Medicare Webinar

The Medicare Rights Center’s free webinar, Health Reform and Medicare, is now available as a recorded presentation on its web site.

Medicare Rights Center President Joe Baker discussed Medicare changes arising from the Affordable Care Act, including:

- Medicare Part D prescription benefit improvements
- Expansion of Medicare-covered services
- Long-term care services and supports
- Changes to Medicare private health plans (Medicare Advantage)
- And much more

Webinar viewers will be able to hear a recording of the presentation while following along with a slideshow.

Click here to view this webinar.

The Medicare Rights Center is the largest independent source of health care information and assistance in the United States for people with Medicare. Visit them at www.medicarerights.org.

New Data on CHIPRA, Medical Malpractice, Childhood Obesity Laws, HCBS, State Budgets, and More

Statehealthfacts.org has recently added new and updated data on Demographics & the Economy, Health Status, Medicaid & CHIP, Medicare, Providers & Service Use, Minority Health, HIV/AIDS, and Health Reform. You can also view a list of all recent updates.

Demographics & the Economy

• State Fiscal Distress
  Measures of aggregate state rankings in foreclosures, unemployment, and food stamp participation have been updated with the latest information from RealtyTrac, the United States Department of Agriculture (USDA), and the Bureau of Labor Statistics (BLS). Updated data on states with projected budget shortfalls for state fiscal year (SFY) 2012 have been added from the Center on Budget and Policy Priorities (CBPP).
• State Budgets
  The latest state-by-state information from the National Association of State Budget Officers (NASBO) on total state expenditures, per capita state spending, and the distribution of general fund spending is available for SFY2009.
  
• State or Federal Inmates
  Updated data from the Bureau of Justice Statistics on the number of adult prisoners under state jurisdiction, adult prisoners by gender, and the incarceration rate per 100,000 population have been added for all states and the nation for 2009.
• Union Employees
  Information on the number of workers represented by unions has been updated for 2010 based on data from the BLS.
• Cigarette Excise Tax
  The most recent data from the American Lung Association on state cigarette excise taxes are available for 2010.

Health Status

• Childhood Obesity and Firearm Safety
  The latest data on state laws addressing childhood obesity and states with firearm laws designed to protect children are now available for 2010 from the American Academy of Pediatrics’ State Legislation Report.
• Public Place Smoking Bans
  Updated information on states with public place smoking bans has been added for all states from the American Nonsmokers’ Rights Foundation for 2011.
  

Medicaid & CHIP

• Medicaid and CHIP Eligibility
  New data from the Kaiser Commission on Medicaid and the Uninsured (KCMU) and the Georgetown University Center for Children and Families on CHIP program type and children’s upper income eligibility limit for Medicaid/CHIP have been added as of January 2011.
• Co-Payments and Premiums for Children in Medicaid/CHIP
  Also new from KCMU and Georgetown University is information on premium and co-payment amounts and requirements as of January 2011.
  
• Children’s Health Insurance Program Reauthorization Act (CHIPRA)
  New data on state adoption of coverage and enrollment options in CHIPRA have been added for all states and the nation as of January 2011 from KCMU and Georgetown University. Also new are data on CHIPRA performance bonus awards for FY2009 and FY2010 from InsureKidsNow.gov.
• Home and Community-Based Services (HCBS)
  Updated data from KCMU and University of California at San Francisco analysis of CMS Form 372 are now available for all states and the nation for 2007. Updated topics include total HCBS waivers, expenditures by waiver type, aged/disabled participants, home health participants, and personal care expenditures.
• State Medicaid Spending
  The latest information from NASBO on the distribution of state Medicaid spending has been added for all states and the nation for SFY2009.

Medicare

• Medicare Drug Benefit
  The latest data on Medicare beneficiaries with prescription drug coverage and low-income subsidy eligible beneficiaries with Medicare prescription drug coverage have been added from the Centers for Medicare and Medicare Services (CMS) as of February 2010.
• Medicare Prescription Drug Plans (PDPs)
  Updated data from Mathematica Policy Research and Kaiser Family Foundation (KFF) analysis of the CMS Prescription Drug Landscape File on the number of Medicare PDPs, PDPs with no deductible, and PDPs with no coverage in the benefit gap are available for all states and the nation for 2011.
  
• Medicare Advantage
  Data on the number of Medicare Advantage contracts and Medicare special needs plan (SNP) offerings have been updated for 2011 from KFF analysis of CMS Landscape Source files.
• Medicare Service Use
  The most recent information on Medicare service use, including short-stay hospitals, skilled nursing facilities, and home health services, has been added from CMS for 2009.

Providers & Service Use

• Medical Malpractice
  Updated data from KFF analysis of the National Practitioner Data Bank Public Use Data File on the number of paid medical malpractice claims, total dollars in paid claims, and average claims payments are now available for all states and the nation for 2009. 
• Medical School Graduates
  The latest information on the number of medical school graduates and medical school graduates by gender has been added from the Association of American Medical Colleges for 2010. Data from 2002 through 2010 are available for trend analysis.
  

Minority Health

• Medical School Graduates
  Also updated from the Association of American Medical Colleges are state-by-state data on medical school graduates by race/ethnicity and Hispanic ethnicity.

HIV/AIDS

• Syringe Exchange Programs
  The most recent information from the North American Syringe Exchange Network on states with sterile syringe exchange programs has been added for 2011.

Health Reform

• Federal Lawsuit
  Updated information on states that have joined the federal lawsuit against the Affordable Care Act is now available from the National Council of State Legislatures for 2011.

Statehealthfacts.org is a Kaiser Family Foundation website.

Time to Fill the Doughnuts — Health Care Reform and Medicare Part D | Health Policy and Reform

By William H. Shrank, M.D., M.S.H.S., and Niteesh K. Choudhry, M.D., Ph.D.

The passage of the Affordable Care Act (ACA) in March 2010 promised to put an end to the “doughnut hole,” the gap in prescription-drug coverage that is the most controversial component of the Medicare Part D benefit.¹ Several months ago, seniors who had reached the spending threshold that marked the beginning of their doughnut hole began to receive their $250 rebate checks. Incrementally between now and 2020, the coverage gap will be filled with subsidies from manufacturers of brand-name drugs and from the federal government. Thus, the ACA, like Part D itself, has expanded coverage for prescription medications — but it has done so in a complex manner that owes more to political wrangling than to any straightforward effort to promote health and cost-effective medication use. The plan for filling in the doughnut hole will most likely confuse many beneficiaries and, at least temporarily, work against cost consciousness, and providers and payers will need to assist patients in navigating the benefit and identifying affordable medications in the years leading up to 2020.
More

Out-of-Pocket Burden of Health Care Spending and the Adequacy of the Medicare Part D Low-Income Subsidy - The Commonwealth Fund

Authors: Becky A. Briesacher, Ph.D., Dennis Ross-Degnan, Sc.D., Anita K. Wagner, Pharm.D., Dr.P.H., Hassan Fouayzi, M.S., Fang Zhang, Ph.D., Jerry H. Gurwitz, M.D., and Stephen B. Soumerai, Sc.D.

Medications are among the biggest drivers of out-of-pocket health care costs in the United States. The burden falls particularly heavy on older adults, who, on average, take four to five drugs on a regular basis. This Commonwealth Fund–supported study examined the amount of household resources allocated to out-of-pocket health spending in the year before Medicare's Part D drug benefit took effect.

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What the Study Found

• In the year prior to Part D, more than half of Medicare families faced "burdensome" health care costs, meaning they spent more than 40 percent of their household resources on health care, after paying for housing, food, and other essentials.
• Medicare families in poor health directed 68 percent of nonessential resources to health care.
• Nearly two-thirds of out-of-pocket health care spending went to health insurance premiums and medications.
• About one-quarter of Medicare families with burdensome health care costs were not eligible for a low-income sub

Full Article

Improvements to Medicare Health and Drug Plans

AARP Press Release

WASHINGTON—AARP today submitted comments on regulations proposed by the Centers for Medicare and Medicaid Services (CMS). Many of the proposed regulations for Medicare health and prescription drug plans could improve care, lower costs and simplify enrollment for people in Medicare.

AARP Legislative Policy Director David Certner, the author of the comments, said: “We applaud CMS for working to continually improve the Medicare plans that millions of seniors rely on. While we recommend several areas to strengthen these regulations, on the whole, they will simplify and improve the plans available to people in Medicare.”

Excerpts from AARP’s letter to CMS follow:

On simplifying election periods for Medicare health and drug plans: “AARP strongly supports efforts to simplify beneficiary enrollment for Parts C and D. However, AARP is concerned that this change could result in beneficiary confusion and/or missed enrollment opportunities unless it is widely and effectively promoted. Therefore, AARP urges CMS to work with plan sponsors and beneficiary advocates to develop a public education campaign that will help ensure that all beneficiaries are aware of the new dates for the annual coordinated election period. AARP further believes that Congress should put Medicare fee-for-service and MA on a level playing field by creating an open enrollment period that makes all Medigap products available without regard to health status or pre-existing conditions.”

On income-related Part D premiums: “AARP did not support imposing an income-related premium in the Medicare Part D program. AARP has concerns about the potentially adverse effect of the income related Part D premium on the Part D program and its enrollees…. Nevertheless, we commend CMS for its efforts to develop timely regulations to implement the ACA provision. We are particularly supportive of the proposal in the NPRM to give Medicare beneficiaries a 3-month grace period, and an extension of the grace period for good cause, to pay the Part D Income-Related Monthly Adjustment Amount before their coverage could be terminated.”

On eliminating Part D cost-sharing for “dual eligibles” receiving care at home: “AARP supports the promulgation of this provision, which will create equity in Part D cost-sharing between institutionalized full-benefit dual eligibles and full-benefit dual eligibles receiving substantially the same services in the community.”

On Medicare Advantage cost-sharing for covered preventive care: “AARP strongly supports requiring [MA plans], including section 1876 cost plans, to provide preventive benefits at zero cost-sharing. This measure would align policy for the MA program with the FFS Medicare requirements. It makes sense in terms of providing appropriate incentives to MA enrollees to obtain preventive services and should have the longer term effect of improving health outcomes for the Medicare population.”

To obtain a complete copy of AARP’s letter to CMS, please contact AARP Media Relations at 202-434-2560 or media@aarp.org.

More Details on Doughnut Hole, Income-Related Part D Premiums

In just a few short weeks, the doughnut hole will begin to close in earnest. Until now, consumers who reached the doughnut hole—the coverage gap in Medicare’s prescription drug benefit—have been responsible for paying the full cost of their drugs. But starting next year, these consumers will receive a discount on drugs they purchase while in the gap. This change to the Medicare drug benefit, also known as Part D, is the result of the Affordable Care Act (ACA), which gradually phases out the doughnut hole through the year 2020, when it will be completely eliminated. In 2011, people who enter the gap will receive a 50 percent discount on brand-name drugs and a 7 percent discount on both generic drugs and drugs compounded at the pharmacy. Furthermore, the 50 percent discount will count toward consumers’ out-of-pocket limit, which is used to determine when they get out of the doughnut hole and enter catastrophic coverage. This means Medicare consumers will spend less while in the doughnut hole.

Also as a result of the ACA, the Social Security Administration (SSA) published an interim final rule regarding the assessment of higher Part D premiums for higher-income Medicare consumers beginning next year. From 2011 through 2019 individuals who have modified adjusted gross income (MAGI) at or above $85,000 per year and couples whose MAGI is at or above 170,000 per year will be subject to additional premiums for Part D. The premiums will be assessed on a sliding scale that is pegged to income levels. The extra amount will, in most cases, be directly deducted from the individual’s Social Security check. While the income thresholds of $85,000 and $170,000 will be frozen through 2019, SSA may change them after that year.  

The formula used to calculate MAGI is based on federal taxes filed two years prior to the year when the income-related premium assessment takes place. As under Part B, the rule states that individuals may request that SSA use more current tax data to calculate MAGI if they have experienced a major life-changing event, as defined by the regulations, or may appeal the misapplication of an income-related premium expense. 

Read the Medicare Rights Center’s fact sheet: Health Reform and Medicare: The Doughnut Hole in 2011.

Read more about income-related Part D premiums.

Read the interim final rule on income-related Part D premiums.

Anger, Seniors And Ad Campaigns: Health Reform Politics

A poll released Tuesday shows most seniors in Medicare's prescription drug benefit program don't know that the health law "closes Part D's coverage gap," The Hill's Healthwatch blog reports. "The findings are bad news for Democrats, who are hoping that seniors - among the most reliable voters in midterm elections - will flock to the polls next month in support of the party who backed the new benefits. Yet just 20 percent of Part D beneficiaries are aware that the law cuts the cost of name-brand drug in half next year through the donut hole, according to the survey, conducted by KRC Research for the Medicare Today coalition, an advocacy group" (Lillis, 10/12).

Full Article

Sebelius Announces 1 Million Medicare Beneficiaries Have Received Prescription Drug Cost Relief Under The Affordable Care Act

Image via WikipediaDepartment of Health and Human Services Secretary Kathleen Sebelius today announced that more than 1 million Medicare beneficiaries have received prescription drug cost relief through the Affordable Care Act. As part of the health insurance reform law's step-by-step efforts to close the Medicare Part D prescription drug coverage gap, eligible beneficiaries who fall in this "donut hole" this year are mailed a one-time, tax-free $250 rebate check. More than a quarter of the 4 million checks Medicare expects to distribute have been received by eligible Medicare beneficiaries.

"Many seniors and people with disabilities on Medicare face extraordinary prescription drug costs, and too often stop following the drug regimens that their doctors have recommended as a result," said Secretary Sebelius. "These checks will make a difference in helping seniors continue to get the medications they need, and are one of many ways that the Affordable Care Act is helping seniors."

Nationwide, 1 million Medicare beneficiaries have already been mailed their rebates and more beneficiaries will be receiving checks in the coming months as they enter the coverage gap. Eligible beneficiaries receive these checks automatically in the mail when they reach the donut hole, and they don't have to sign-up to be eligible for the rebates.

Rebate checks will help people with their drug costs this year. Next year, those who fall into the donut hole will receive a 50-percent discount on covered brand name medications while in the donut hole. Every year, the amount Medicare beneficiaries pay in cost sharing will decrease markedly until the coverage gap is closed.

The closing of the donut hole is just one of the ways seniors benefit from the Affordable Care Act. In addition to savings on prescription drugs, the law provides new benefits to Medicare beneficiaries when they visit their doctor. All beneficiaries will receive free preventive care services like mammograms and certain colon cancer tests and a free annual physical starting in 2011 in Original Medicare. Additionally, seniors can expect to save an average of nearly $200 per year in premiums by 2018 compared to what they would have paid without the new law, and most beneficiaries will also see a significant reduction in their Medicare coinsurance as a result of the Affordable Care Act.

The Affordable Care Act also contains important new tools to help crack down on criminals seeking to scam seniors and steal taxpayer dollars. Last week, HHS and the Department of Justice held their second regional fraud prevention summit in Los Angeles that brought together law enforcement experts, providers and seniors to help utilize these new tools to fight fraud and protect seniors.

The Affordable Care Act strengthens the screenings for health care providers who want to participate in Medicaid or Medicare, enables enforcement officials to see health care claims data from around the country into a single, searchable database, and strengthens the penalties for criminals. The reduction in waste, fraud and abuse returns savings to the Medicare Trust Fund to strengthen the program into the future.

Seniors are encouraged to contact 1-800-MEDICARE to report any solicitations of personal information, or go here.
For more information on how the Affordable Care Act benefits seniors, visit here.

Related articles by Zemanta

• Landmark: Number of Donut Hole Rebate Checks Passes One Million (whitehouse.gov)
• Seniors Already Seeing Lower Prescription Drug Costs (whitehouse.gov)
• White House Touts Medicare Rebates (thecaucus.blogs.nytimes.com)

NCOA Offers Two New Tools for Seniors in Need of Benefits

The National Council on Aging’s National Center for Benefits Outreach & Enrollment (NCBOE) has developed a new data mapping tool that allows users to search for information about eligibility and enrollment trends in Medicare and Medicaid benefits programs. The map also provides statistics on the number of individuals eligible for or enrolled in programs such as Medicare Part D Extra Help.

For guidance on how to navigate the map, please go to http://ssl4.benefitscheckup.org/datamap/

NCBOE also has published a new issue brief called Extra Help to Keep Extra Help: Assisting LIS Beneficiaries Who Lose Their Deemed Status. It offers promising strategies using list-driven communications to help beneficiaries adversely affected by the redeeming process regain and retain the Medicare Part D Low-Income Subsidy.

To download a copy of the http://www.centerforbenefits.org/NCBOE%20Issue%20Brief%206.pdf

To learn more about the National Council on Aging’s National Center for Benefits Outreach & Enrollment, please go to http://www.ncoa.org/

Life-Changing Events Affecting Income-Related Monthly Adjustment Amounts to Medicare Part B Premiums

Amendments to Regulations Regarding Major Life-Changing Events Affecting Income-Related Monthly Adjustment Amounts to Medicare Part B Premiums

AGENCY: Social Security Administration.

ACTION: Interim rule with request for comments.

SUMMARY: SSA is modifying its regulations to clarify and revise what it considers major life-changing events for the Medicare Part B income- related monthly adjustment amount (IRMAA) and what evidence is required to support a claim of a major life-changing event. Recent changes in the economy and other unforeseen events have had a significant effect on many Medicare Part B beneficiaries. The changes we are making in this interim final rule will allow SSA to respond appropriately to circumstances brought about by the current economic climate and other unforeseen events, as described below.

DATES:
Effective Date: This interim rule will be effective July 15, 2010.
Comment Date: To ensure that your comments are considered, we must receive them no later than September 13, 2010.

ADDRESSES:
You may submit comments by any one of three methods-- Internet, fax, or mail. Do not submit the same comments multiple times or by more than one method. Regardless of which method you choose, please state that your comments refer to Docket No. SSA-2009-0078 so that we may associate your comments with the correct regulation. Caution: You should be careful to include in your comments only information that you wish to make publicly available. We strongly urge you not to include in your comments any personal information such as Social Security numbers or medical information.

1. Internet: We strongly recommend that you submit your comments via the Internet. Please visit the Federal eRulemaking portal at http:/ /www.regulations.gov. Use the Search function to find docket number SSA-2009-0078. The system will issue a tracking number to confirm your submission. You will not be able to view your comment immediately because we must post each comment manually. It may take up to a week for your comment to be viewable.

2. Fax: Fax comments to (410) 966-2830.

3. Mail: Mail your comments to the Office of Regulations, Social Security Administration, 107 Altmeyer Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401.
Read Complete Notice

TIME GOES BY | GRAY MATTERS: Health Care Reform Benefits for Elders

by Saul Friedman (bio) 
The final health reform law is much too long, more than 2,000 pages, mostly because of dozens of compromises to get Democrats (liberals and conservatives) on board, and in a vain effort to get support from Republicans who marched in lockstep to vote no like, say, the goosestepping North Korean army.

Nevertheless, a 2,000 page bill is not unusual for even routine legislation like the budget but the length reflects these contentious days in the Congress, especially for such a massive and comprehensive legislative enterprise as the historic Patient Protection and Affordable Care Act.

Most of us know, or will soon see, the main benefits, requiring insurance and drug companies to provide – with the government’s help – affordable health care and prescription drug coverage for 40 million uninsured Americans, including children, no matter their current health problems.

But in reviewing the bill and the analyses of various organizations, the PPACA, as it has become known, includes some valuable unpublicized benefit nuggets. For example, the June AARP Bulletin tells me than the law has set aside $2 billion over five years to encourage states to use Medicaid dollars to help older people “transition” out of nursing homes to more independent living arrangements – their homes or assisted living.
These patients ought to know about this and take advantage of it; best to stay home or in your community.
Preventive medicine also will be a high priority in the law, from which you’ll benefit in coming years. Just last week, Health and Human Services Secretary Kathleen Sibelius announced the law will allocate $250 million for public health initiatives on preventing and dealing with chronic diseases including curbing tobacco and alcohol abuse (something the British health system is tackling).

She wants to spend the money training hundreds of needed primary care doctors, but lawmakers want more spent on preventive medicine. This is part of the $500 million Prevention and Public Health Fund, the first of its kind under Medicare, created by the act. Money will be available through grants to community clinics, hospitals and researchers.

If you didn’t already know, beginning next year, all preventive screening and tests for Medicare patients – mammograms, colonoscopies and annual comprehensive physical exams will be free. Private insurers are expect to follow suit; at present, beneficiaries have had to pay 20 percent of the cost and use their yearly deductible.

One of my favorite obscure provisions is in section 4207, which requires employers to “provide a reasonable break time for an employees to express breast milk for her nursing child for one year after the child’s birth” and to provide a place, not a bathroom, for mother to nurse the child.. Other benefits are enhanced for infant care.

The respected Center for Medicare Advocacy has compiled a number of important, but obscure provisions of the reforms. Beginning next year, Medicare Advantage Prescription Drug plans may not manipulate premiums for low-income beneficiaries in order to force them into other plans.
But the HHS Secretary is authorized to auto-enroll low-income beneficiaries who have lost their plans into more advantageous plans. Effective January 1, 2011, an individual whose spouse dies in the middle of a low-income eligibility period is granted continued eligibility for a full year beyond the date when his/her eligibility would end.

Of course he/she could reapply for the low income benefits. You should check with the center to see if you qualify as low-income.

“Dual eligibles,” low-income individuals who are eligible for both Medicaid (health care for the poor) and Medicare, have always presented the Centers for Medicare and Medicaid Services (CMS) with bureaucratic problems. The Republican Part D law, took away availability for cheap medicines from Medicaid beneficiaries and forced them to use more expensive and limited Medicare Part D, with its co-pays, limitations and the notorious doughnut hole.

Low income people can get “extra help” in paying for drugs. And the doughnut hole is to be phased out slowly. If you fell into the hole, you should have gotten a $250 rebate by now. That’s a pittance, but the next big change comes next year when the cost of brand named drugs, while you’re in the hole, will be cut by 50 percent.

A reader asks why the Republican congress in 2003 created the doughnut hole during which the beneficiary must pay the full, retail cost of his drug. This year the beneficiary who has purchased $2, 830 in drugs, at the cost of small co-pays, must pay, while in the hole, the full price until he/she reaches $4,300 in out of pocket costs.

The congress created the hole, which has grown larger each year based on the economic theory called ‘”moral hazard,” which means beneficiaries will buy more drugs that they may not need if there were no such curbs as the doughnut hole.

Put another way, persons with good auto insurance are more likely to drive recklessly and have accidents. For the Republican sponsors it was their way of saving money by forcing beneficiaries to pay more out of pocket.

Anyway, the problems of dual eligibles will be assigned to a new Federal Coordinated Care Office to integrate benefits under Medicaid and Medicare and, under the law, to provide dual eligibles “full access to all benefits of both programs.”

Too often the elderly poor who are on Medicare do not get the full benefits of Medicaid if they are under home care or in a nursing facility.

More specifically for dual eligibles, effective January 1, 2012, the reforms call for the elimination of cost-sharing (co-pays) for Part D drugs for all full benefit, dual-eligible beneficiaries who are receiving Medicaid and Medicare at home or on a nursing institution. The center says, “This provision creates equity in Part D cost sharing between those in institutions and those getting substantially the same services” at home or in assisted living.

Long term care remains, as AARP said, the greatest unmet health care need in the country. Perhaps two-thirds of people who are 65 today will need long term care, at home or in an institutional setting. The U.S. spends $207 billion on long term care, much of it on Medicaid funds which are used by many middle and working class families who game the system by transferring their assets to loved one, impoverishing themselves in order to become eligible.

They should not be condemned, for they have little choice; long term care insurance is expensive and few will spend years paying the premiums for insurance they probably won’t need. Only seven million Americans have long term care insurance. It’s not feasible for a person who is, say 60, to pay for 20 years on the chance he/she will need it.

If it is not needed, the money is lost. And often the insurance companies, several of which have been absorbed by conglomerates, will raise premiums when the elderly beneficiary can least afford it.
According to the center, the reforms call for better regulation of the thousands of nursing facilities, some of which have been literally getting away with murder, neglecting residents mostly because of poorly paid, insufficient staffs. There are perhaps a dozen provisions policing nursing homes to hold them accountable for maltreatment of patients.

Medicare, of course, covers medical needs of nursing home patients, but after 20 to 100 (expensive) days in rehabilitation after a hospitalization, say for a hip replacement, it does not cover long term nursing home care. Medicaid does, but the Congress has been cracking down on those who get rid of their money to get the Medicaid benefits.

The reforms, thanks to the late Senator Edward M. Kennedy, include the modest Community Assistance Services and Supports Act (CLASS) under which employees may voluntarily sign up to contribute $50 a month into a fund which eventually will pay a tiny fraction of the current $150 per day rate for a good nursing home. It’s an obscure provision of the massive health reforms. And it means less than minimal progress in dealing with long term care.

Maybe it deserves obscurity, for while some say it’s a start; I say it’s a shame. The Congress and President Obama, who speaks of his late grandmother in long term care, could have done more. Where is the real concern for older Americans, the fastest growing part of the population?

Finally, for the best and latest information on the 2,000 pages of the PPACA, try The Alliance For Health Reform website.

Write to saulfriedman@comcast.net

TIME GOES BY | GRAY MATTERS: Health Care Reform Benefits for Elders

The Medicare Counselor

The Medicare Counselor is a free publication of the Medicare Rights Center. Each issue will address timely topics that will help you—social workers, health care providers and other professionals—keep up-to-date on important Medicare issues that affect the well-being of your clients.

In this issue:

Hot Topics from the Hotline. My Medigap (Plan E) will no longer be sold after June 1, 2010. Is my coverage going to change? Read the full article.

Closing the Doughnut Hole: Step 1. The Affordable Care Act passed by Congress and signed by President Obama contains a great deal of information, some of which may seem confusing. Read the full article.

Fast Facts: Baby Boomers. 79 million baby boomers will be aging into Medicare starting in 2011. Here are some facts about the population that is changing the face of retirement. Read the full article.

Dear Hannah. My understanding is that Medicare limits ambulance coverage based on the cost of transporting a patient to the closest facility. Is this correct? Read the full article.

Featured Resources 

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TIME GOES BY | GRAY MATTERS: Republicans and the Health Care Reform Law

by Saul Friedman

Nobody likes a sore loser. But congressional Republicans, who have not yet come to terms with the election of Barack Obama, cannot get over the passage, with not a single one of their votes, of the health insurance reforms called the Patient Protection and Affordable Care Act.

Thus the Republicans plan to campaign this summer to repeal the law, which they call unpopular. They have not read the latest polls which say otherwise.

The Wall Street Journal poll found that 55 percent want the reforms to have a chance to work. A Vanity Fair poll found that 42 percent would keep all the provisions. That may be why the Republicans won’t say, specifically, which provision should be repealed.

If they did, they would have to support denying insurance coverage to children with pre-existing conditions like asthma or diabetes which is outlawed by the reforms. Or perhaps the Republicans would force middle-class parents to buy separate policies for their adult children; the reforms would cover them until age 26.

How about getting rid of the provisions lowering the Part D cost of drugs, gradually closing the infamous doughnut hole or paying for cancer-preventive screenings?

Or maybe the Republicans simply don’t want coverage that will be available at low cost for the 40 million men, women and children who have no insurance.

More than a dozen state Republican attorneys general have taken a different tack – a fool’s errand, paid for by taxpayers, which pleads that the courts to stop the reforms and declare unconstitutional the provision mandating that all of us purchase insurance (with and without help from the government), the better to create a healthy risk pool.

I don’t have a clue how Republican-dominated courts may rule, but chances are the mandate will stand for each state similarly requires drivers to buy insurance. State laws regulating real estate also require the purchase of homeowners insurance. Becoming eligible for Social Security generally means automatically becoming a beneficiary for Medicare Part A, and Medicare sets a stiff penalty if beneficiaries do not sign up for Part B or Part D when they are first eligible and have no equivalent coverage.

The latest whine of the sore loser is the Republican criticism of the perfectly straight-forward brochure from Health and Human Services (HHS) Secretary Kathleen Sibelius, explaining the admittedly complicated, many-faceted law, which will take years to have full effect. Republicans call it “propaganda” as if their flacks never heard of such a thing.

Her biggest boo-boo, according to the Republicans, was her defense of the law’s reduction of the slush fund for Medicare Advantage plans which George W. Bush gave us as part of the GOP effort to privatize Medicare. Said Sebelius:

“Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than Original Medicare...The new law levels the plying field by gradually eliminating Medicare overpayments to insurance companies.”

More important, she added, “If you are in a Medicare Advantage plan you will still receive guaranteed Medicare benefits.”

That has not been the case with MA insurers for in April, the Government Accountability Office reported that in 43 percent of MA plans, more than half the beneficiaries were in the “average or poor health group,” meaning they did not receive the best of care.

The reforms will hold all private insurers to a higher stand, mandating that 85 percent of premium income be spent on care. Perhaps the Republicans would repeal that provision.

Here is an example of how ridiculous the sore loser can get. In Britain, the heavy use of alcohol poses a serious health problem for the nation and its National Health Service. As a result, Britain’s National Institute for Health and Clinical Excellence (NICE), which produces guidance on public health, suggested the nation’s doctors question and screen patients on their use of alcohol, the better to understand and treat their health problems and their addiction.

It sounds reasonable. But according to Don McCanne of Physicians for a National Health Plan, America’s Health Insurance Plans (AHIP), a leader in the resistance to the American health reforms, picked on Britain’s socialized health program and blasted NICE for requiring doctors “to invade the privacy of every one of their patients by submitting them to a questionnaire on alcohol use.”

There is no such requirement, but McCanne says AHIP is simply doing its conservative Republican thing, defending the “waste of the superfluous insurance industry” in order to discredit any health reform as “socialist.” I guess we should call this the “booze panel” scare.

Putting aside such silliness, it would be worth understanding how HHS intends to enforce the laws, something advocates have worried about because insurance companies have signaled their intent to poke holes in the reforms. Thus, according to Kaiser Health News, the administration has appointed four watchdogs, with plenty of experience dealing critically with insurance companies.

The new director of the Office of Consumer Information and Insurance Oversight is Jay Angoff, a former Missouri commissioner. They’ll be watching for unseemly premium increases, denials and cancellations of coverage and fraudulent sales pitches.

Finally, there is good news for Medicare Advantage, as well as original Medicare beneficiaries who can get eaten alive by deductibles, co-payments and other out-of-pocket costs. The reforms included changes for the better, including lower costs, in the 10 standard Medigap plans that are now offered in most, but not all states.
The plans with increasing benefits range from A, the most basic; B,C,D, and F, the most popular; G, which is similar to F; and K, L, M and N. You can check them out at the Medicare website.

Depending on the level of coverage one needs and can afford, these plans are designed to fill the gaps in Medicare by paying co-insurance, co-payments, some deductibles and even needed blood transfusions and ambulance service.

Medigap plans cover you throughout the nation and some plans include travel and overseas coverage. With such a policy, many beneficiaries pay virtually nothing towards the cost of their care. And Medicare plus Medigap can end up costing less than Medicare Advantage, which does not have a great record when you’re really sick.

Write to saulfriedman@comcast.net

TIME GOES BY | GRAY MATTERS: Republicans and the Health Care Reform Law

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Consumers Get More Information on Coverage Gap Rebate

For Medicare consumers who this year have fallen into the coverage gap in Medicare Part D, help is on the way. In mid-June, $250 rebate checks will begin to be mailed to consumers who have reached the gap, which is commonly known as the “doughnut hole.” Consumers who reach the doughnut hole will automatically receive a one-time $250 check. People with Medicare who have Extra Help, the federal program that helps pay for prescription drugs, will not receive a rebate check.

Last week, the Centers for Medicare & Medicaid Services (CMS) released a brochure that provides more details about the rebate. According to the brochure, subsequent mailings of the rebate checks will occur monthly throughout the year. There is no need to apply or fill out any forms, and consumers should not provide personal information to anyone who contacts them about the check. To report fraud related to the rebate, call 1-800-MEDICARE (1-800-633-4227).

Read the brochure.

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Program to Close the Coverage Gap Moves Forward

People with Medicare who enter the Part D prescription drug coverage gap, also known as the “doughnut hole,” in 2011 will automatically receive a 50 percent discount on brand-name drugs and biologics at the time they purchase their medicines, according to final guidance released by the Centers for Medicare & Medicaid Services (CMS) on May 12, 2010. CMS expects that all drug manufacturers will enter into discount agreements, which effectively means that the discount program will not change the brand-name drugs and biologics that are covered under Part D.

SHIIP helps NC Medicare recipients affected by Aetna sanctions | citizen-times.com | Asheville Citizen-Times

Insurance Commissioner Wayne Goodwin today announced that the Department’s SHIIP program is available to help some 23,000 N.C. Medicare recipients who may be affected by Medicare’s sanction and suspension of Aetna Insurance Company’s marketing and enrollment of its Part D prescription drug plans. The sanction will remain in effect until the company demonstrates that it has corrected the cited problems. Although the sanction does not impact current Aetna Part D members, if they are experiencing difficulties in getting their prescriptions SHIIP is here to help.

“North Carolina has more than 23,000 Medicare recipients enrolled in Aetna Part D plans, and I want those folks to know that if they’ve had delays getting their prescriptions filled, our SHIIP program can help,” said Commissioner Goodwin. “We don’t anticipate recipients having too much trouble – and remember their current coverage is not impacted – but if someone has a Medicare Part D plan with Aetna, and they’re having problems they should call our SHIIP helpline at 1-800-443-9354.”

Medicare issued the intermediate sanction because the plan has failed to fully meet its obligations to Medicare beneficiaries.

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Medical Conditions That Put Seniors At Risk Of Falling Into Medicare 'Donut Hole' - Health News - redOrbit

Among seniors, women and patients with diabetes and dementia are the most likely to fall into the Medicare Part D prescription drug plan "donut hole" — the gap occurring after beneficiaries reach their annual coverage limit and before catastrophic coverage kicks in — according to new research published online in the Journal of General Internal Medicine.

Because this gap leaves them exposed to unsubsidized medication costs, these clinically vulnerable groups should be counseled on how to best manage costs through either drug substitution or discontinuation of specific non-essential medications, according to Susan Ettner, professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA and the study's lead author.
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Impact on Senior Citizens of Rising Drug Prices in Medicare to Be Hearing Topic

The Special Committee on Aging will convene Wednesday, March 17, for a hearing to examine the rise of prescription drug prices in America and its impact on senior citizens who participate in the Medicare Part D program. Senator Bill Nelson (D-FL) will be the acting chairman.

Witnesses will offer testimony on various topics, including cost-sharing under Part D, how pharmaceutical pricing makes it difficult for Part D plans to negotiate discounts, and policy options for closing the doughnut hole and curbing escalating drug prices, according to a news release from the office of the committee chairman, Sen. Herb Kohl (D-WI).

“Seniors Feeling the Squeeze: Rising Drug Prices and the Part D Program,” will convene at 2:30 p.m. in Room 562, Dirksen Senate Office Building.

Among those providing testimony will be the following.

● Dr. Gerard Anderson, Director, Center for Hospital Finance and Management, and Professor, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
● John Dicken, Director, Health Care, U.S. Government Accountability Office, Washington, D.C.
● Greg Hamilton, pharmaceutical industry expert, Algonquin, IL
● Willafay McKenna, Medicare Part D beneficiary, Williamsburg, VA
● John Calfee, Resident Scholar, American Enterprise Institute, Washington, D.C.

The hearing can be viewed live or at a later time by a webcast. A link to the webcast can be found at the committee’s website: http://www.aging.senate.gov/