Action, Not Further “Guidance”, Needed to Help Vulnerable Medicare Beneficiaries Access their Drugs

Action, Not Further “Guidance”, Needed to Help Vulnerable Medicare Beneficiaries Access their Drugs

Despite firmer direction issued to Medicare Part D prescription drug plans by the Bush administration last Friday, advocates remain concerned about the ability of Medicare beneficiaries to access their needed prescription drugs during the early days of the Part D “rollout.” As widely reported by advocates and in the media, many individuals who are dually eligible for Medicare and Medi-Cal have had problems accessing their prescription drugs, often leaving the pharmacy empty-handed.

Although the Bush Administration memoranda provide “further guidance requiring that Part D sponsor implementation efforts be strengthened” by providing better and faster access to plan information by pharmacists, including appropriate cost-sharing levels for low-income beneficiaries, these directives do little to improve on already lax requirements on Part D plans.

The recent action by the Bush administration, “re-emphasizing” rules already in place, will make no difference until the electronic data and communication systems are fixed and operating smoothly. “These new directives in no way alleviate the need for the emergency coverage for dual eligibles recently announced by the Governor.” commented David Lipschutz, Staff Attorney at California Health Advocates (CHA), a Medicare advocacy organization.

This recent development underscores the deference given to these private commercial plans at the expense of adequate Medicare beneficiary protections. Up to this breaking point, CMS has recommended, but not required Part D plans to provide emergency supplies of drugs that the dually eligible are currently taking but might not be included in their Part D plan’s formulary. It is an indictment against the implementation of the new drug benefit that at least twenty states needed to declare ‘public health emergencies’ before the Bush administration acknowledged the magnitude of the problem. Many of these problems stem from the fact that the new Part D benefit is only available through private, commercial plans with no government fallback. The Bush administration and Congress turned this benefit over to private industry instead of including it as part of the Medicare package.

Also in need of attention is the lack of access to the drug plans, including Medicare Advantage (Medicare HMOs) plans. The companies are apparently overwhelmed by calls and also are lacking knowledgeable customer service staff that can help Medicare patients with understanding how their Part D plan works, what drugs the plan will actually cover and how much a plan member will need to pay. “Erroneous information abounds both on the phone and on the web, it is unacceptable for people who are in need of medication to be forced to call one phone number after another in order to learn about how this tremendous change in their drug coverage will affect their unique health care situation.” stated Clare Smith, CEO California Health Advocates.

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.