Medicare Compliance & Reimbursement

Rocky Part D rollout leaves many without prescription drug access

While system glitches leave many Part D beneficiaries without access to their prescription drugs, states are stepping up to protect their own--at considerable cost.

In spite of the Centers for Medicare & Medicaid Services' comprehensive contingency plan, millions of dually eligible benes transferring from Medicaid drug coverage to Medicare Part D have had problems filling their prescriptions since the plan began Jan. 1. As state officials had feared, bewildered benes are turning to Medicaid for answers.

Lacking coverage and subsidy eligibility records are among the most common problems benes have reported. Many pharmacists are unable to find Part D enrollment records for benes trying to fill their prescriptions, while others end up overcharging low-income benes who, according to the system, aren't eligible for drug subsidies.

Nevertheless, pharmacists around the country are filling a million prescriptions a day, and many seniors are reporting that they are already saving money from the benefit, say CMS and Department of Health and Human Services secretary Mike Leavitt. But Leavitt acknowledges that some seniors are experiencing problems getting pharmacies to fill their prescriptions. "We are working as quickly as possible to resolve these problems, and no senior should leave the pharmacy without the prescription drugs they need," he says.

States Step In To Bridge The Gap

At least 26 states have already stepped in to offer immediate prescription protection and fulfillment to dual eligibles, allowing pharmacists to bill state programs directly. States leading the movement include Arkansas, California, Connecticut, Illinois, Kansas, Maine, Massachusetts, New Hampshire, North Dakota, South Dakota and Vermont.

Those states that enact measures to extend drug coverage to Medicare benes may not receive federal reimbursement for their efforts, however. "Under this program, [CMS doesn't] have the authority to pay states directly," notes CMS Administrator Mark McClellan. "People are in Medicare drug plans and it's the Medicare plans that are supposed to pay for the medications."

"That kind of defies the old good-neighbor rule," complains Gov. Mike Huckabee (R-AR). "They borrowed our lawn mower, and they gave us back a pair of scissors." Many state officials have expressed similar sentiments, vowing to press Washington for reimbursements. In addition, a bipartisan senate group plans to sponsor legislation that forces CMS to reimburse states for 100 percent of their Part D-related costs, plus interest. The legislation would also require HHS to recover overpayments to Part D drug plans and return the money to Medicare.

In CMS' own effort to ensure enrollees receive their prescriptions, the agency directed Medicare carriers to provide benes with a 30-day emergency supply of any drugs they were taking before the Medicare prescription drug benefit began Jan. 1. CMS also requires carriers to take steps to prevent low-income benes from paying more than $2 for a generic drug and $5 for a brand-name drug.

CMS, HHS Defend Enrollment Criticism

CMS and HHS are quick to defend the enrollment system, assuring that it's working for most seniors. In addition to the 1 million benes who enrolled in stand-alone drug plans during the first 30 days of the prescription drug program, nearly 24 million benes now have Medicare prescription drug coverage, reports HHS. More than 2.6 million people signed up for the stand-alone drug plan in the last 30 days. "Enrollment in the new Medicare drug benefit is exceeding our expectations and keeping us on track to reach our goal of 28 to 30 million enrollees in the first year," says Leavitt.

"Many seniors are signing up for coverage on-line, often with the help of thousands of local partner organizations or family members, and many more continue to enroll over the phone and using paper applications as well," adds McClellan. "Hundreds of thousands of seniors are saving money every day, and we are working around the clock to make sure all seniors who participate can take full advantage of the benefit."

Since November, 1.6 million benes have signed up online, and CMS has been processing an average of more than 20,000 online enrollments a day through the end of last week, McClellan reports.

CMS released state-by-state Part D enrollment figures Jan. 19 and reports the following national enrollment figures as of Jan. 13:

• Stand-alone drug plans: about 3.6 million (2.6 million since Dec. 13).

• Auto-enrolled dual eligibles: 6.2 million, including 600,000 in Medicare Advantage plans.

• Medicare Advantage: 4.5 million, plus the 600,000 dual eligible benes.

• Medicare retiree subsidy: about 6.4 million. Also, approximately 1 million retirees have employer coverage that incorporates or supplements Medicare's coverage. Another estimated 500,000 retirees have coverage that is as good as Medicare's.

• Federal (TRICARE/Federal Employee Health Benefits program) retirees: 3.1 million.

To view CMS' state-by-state enrollment figures,
visit www.cms.hhs.gov/apps/media/press/release.aspCounter=1754.