Medicare Compliance & Reimbursement

GAO report questions protections for benes--much to CMS' displeasure.

A safety net is in place to ensure comprehensive, uninterrupted drug coverage for dual eligibles during their transition to Medicare Part D--but it contains some significant holes, a new report charges.

The contingency plans that are in place to protect full-benefit dual eligibles from losing Medicaid coverage when they transfer to Medicare Part D may not be enough to guarantee that all enrollees will be able to obtain the drugs they need starting Jan. 1, 2006, the Government Accountability Office cautions in a recent report. Three main problem areas, plus flaws in its four key contingency plans, suggest that the Centers for Medicare & Medicaid Services may be overconfident, or GAO may be overcritical. Congress Shows Growing Concern After citing potential coverage problems for dual eligibles to CMS earlier this year, Max Baucus (D-MT), Senate Finance Committee ranking member, redirected his concerns to the GAO. Despite CMS' contingency plans, some of the 6 million enrollees who qualify for benefits under both Medicare and Medicaid may still find themselves without drug coverage after Jan. 1, Baucus notes. Specifically, the single-day transition from one type of drug coverage to another could create difficulties in ensuring that pharmacies will fill prescriptions for this vulnerable population.

To evaluate the transition process and the protections in place to fulfill dual eligibles' drug needs, Baucus asked GAO to specifically review 1) potential problems that may arise during dual eligibles' transition from Medicaid to Medicare; and 2) CMS', prescription drug plans' and states' contingency plans to respond to these potential problems should they arise.

The GAO upheld Baucus' concerns upon its review. "Although each of these contingency plans is useful in mitigating risks for dual-eligible beneficiaries, their effectiveness is uncertain," notes Kathleen M. King, the GAO's health care director. "While we credit [CMS] for taking the steps to mitigate potential risk for dual-eligible beneficiaries, we believe that the agency's complete confidence in contingency plans that have yet to be fully tested, publicized or implemented may be premature," she adds. 3 Problem Areas Leave Room For Coverage Gaps In the first part of its report, GAO identifies these three problems with the current set of CMS, PDP and state contingencies for dual eligibles' drug coverage:

• Potential inaccuracies in state or federal data may prevent CMS from identifying some individuals for automatic enrollment in a PDP.

• CMS may not identify and auto-enroll all benes in time if they become dually eligible in late 2005 and beyond.

• Benes' prescription drugs may not be on their PDP formulary, or their customary pharmacy may not be in their PDP pharmacy network. Automatic Enrollment Contingency Leaves Pharmacies With Scant POS Preparations In the second part of the report, [...]