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Switch to Medicare Drug Coverage Threatens Nursing Home Residents, Paper Concludes

  • November 17th, 2005

When new Medicare prescription drug plan (Medicare Part D) goes into effect on January 1, 2006, some residents of nursing homes and assisted living facilities may be cut off from the prescription drugs they need, according to a new paper by the Center for Medicare Advocacy.

Nursing home residents who are eligible for both Medicaid and Medicare '“ so-called "dual eligibles" -- are scheduled to lose their Medicaid drug coverage and be switched to one of the many Medicare drug plans when the Medicare drug benefit takes effect. The paper, written by Toby S. Edelman, Esq., examines the impact of the changeover to the new drug plan on individuals in nursing homes or assisted living facilities. (ElderLawAnswers explored this issue in an investigative article published in May 2005.)

Following are some of the areas of concern Edelman raises:

  • Who will act for cognitively impaired residents? To enroll in the right Medicare drug plan, participants must be actively involved in choosing a plan, and it isn't clear who will act on behalf of nursing home and assisted living residents who have cognitive problems. Different drug plans cover different drugs, and participants must look at every plan to determine if it covers their drugs. Because many nursing home residents are Medicaid recipients, they will be automatically enrolled in a plan if they don't choose one. If the plan the resident ends up with does not cover a drug the resident takes, the plan will choose a different drug regardless of whether it is in the best interest of the resident. To fight this, the resident would have to appeal. According to the Center for Medicare Advocacy, most residents do not have a surrogate decision maker appointed by law, and the steps involved in choosing a plan or appealing drug coverage could be a problem for residents who are unable to make decisions on their own.
  • Who will help residents find alternative sources for non-covered drugs? Medicare Part D excludes over-the-counter drugs and certain other drugs from coverage. Residents need a way to receive information on alternative funding for the drugs no longer covered. While Medicaid or state programs may help pay for these drugs, nursing home and assisted facility residents need help finding these programs and applying for them.
  • How will conflicts with the Nursing Home Reform Act be resolved? It is unclear how differences between the Nursing Home Reform Act and Medicare Part D will be worked out. The Nursing Home Reform Act calls for a pharmacist to undertake a monthly review of all drugs a resident is taking to determine if they are appropriate. Under Medicare Part D, a medication therapy management program (MTMP) reviews drug usage of Medicare beneficiaries who have multiple chronic diseases, take multiple Part D drugs, and incur high annual costs for Part D-covered drugs. There is no guidance on what to do if there is a difference of opinion between the MTMP and the pharmacist.

"The complexities of Part D are intensified for nursing home and assisted living and board and care residents," the paper concludes. "Many questions remain about how and whether residents will be able to get the prescription drugs they need."

For the full paper, "Medicare Prescription Drug Coverage for Residents of Nursing Homes and Assisted Living Facilities: Special Problems and Concerns," click here.

This paper was part of a group of papers prepared by the Center for Medicare Advocacy with funding from the Kaiser Family Foundation. Other papers discuss Medicare Part D's affects on the appeals process and on dual eligibles. To see all the papers, click here.

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Last Modified: 11/17/2005

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