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Concern Mounts Over Drug Coverage for 'Dual Eligibles'

  • April 1st, 2005

Some 6.4 million low-income Medicare beneficiaries -- including most nursing home residents -- will lose their Medicaid prescription drug coverage when the new Medicare drug program begins January 1, 2006.

Although Medicare will take over the drug coverage of those who qualify for both Medicaid and Medicare '“ so-called "dual eligibles" -- there is growing concern that many of them could have life-threatening lapses in coverage because of bureaucratic requirements and differences in the specific drugs the two programs cover. The Medicare Rights Center, a beneficiary advocacy group, calls the current plan "a train wreck waiting to happen."

The new Medicare law gives dual eligibles six weeks '“ from November 15, 2005 to January 1, 2006 -- to pick a Medicare prescription drug plan that will take over their drug coverage. But nearly half of dual eligibles have trouble reading or understanding information and a quarter are in nursing homes, according to a report on National Public Radio's Morning Edition. Meanwhile, more affluent and generally healthier Medicare beneficiaries who do not qualify for Medicaid will be given six months to choose a plan '“ until May 15, 2006.

To address this problem, the federal Centers for Medicare & Medicaid Services, which is in charge of the changeover, says it will automatically enroll dual eligibles in a randomly assigned plan by early October. But this could result in beneficiaries being assigned to the wrong plan '“ one that doesn't' cover the drugs they take or that doesn't' work with the pharmacy the beneficiary uses.

The situation is particularly acute for nursing home residents, many of whom suffer from dementia or are otherwise unable to cope with the paperwork involved in switching plans or filing appeals. To take just one example, Medicare does not cover certain anti-seizure drugs commonly used in nursing homes. It appears that nursing home patients in some states will not obtain coverage for these drugs.

There are also concerns that states are not equipped to identify all of their dually eligible residents so they can be notified of the change in coverage.

"The systems are not, and will not be in place to maintain consistent drug coverage for the most vulnerable Americans," said the Medicare Rights Center's president, Robert M. Hayes. Unless the rules are improved, he said, "millions of Americans in great need will face needless illness, suffering and a greater risk of premature death."

Sen. Jay Rockefeller (D-W.Va.) has introduced legislation that would put dual eligibles on the same footing as regular beneficiaries, giving them six months more to transition to the new Medicare drug benefit.

"The dual eligibles -- who are after all the poorest of the poor, the most fragile of the fragile -- they have to make this transition in six weeks," Rockefeller told NPR. "But if you're not a dual eligible, i.e., you're healthy or wealthy or all the rest of it, you have six months to make the transition."

To hear the NPR report, click here.

For a timeline on implementation of the Medicare drug benefit, click here.

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Last Modified: 04/01/2005

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