Will Medicare D get a Passing Grade?

(Part 2)

Lisa Hoffman and Charles Atkins

Published 9/28/2005


Today Lisa and I would like to finish our interview with Rebecca Ganci, a paralegal with The Center for Medicare Advocacy. Our topic is Medicare D and trying to get a handle on this new drug benefit that goes live January 1, 2006.

"Who funds these Prescription Drug Plans?" I ask Rebecca, "Are these run by the government?"

"Well, they’re funded by the government and the Part D premiums, but the drug plans themselves will be private entities," Rebecca explains.

"Are they for non profits?"

"Not necessarily, we understand that many of them are major insurance companies, pharmacies and other entities, some may be for profit, others non profit."

"Rebecca, you mentioned the co-pays and the deductible and there’s also the so-called donut hole, where a person who goes over the $2250 limit has to pay the full cost of medications until they hit a ceiling of $5100 when the plan kicks in again and provides 95% coverage. This is a lot of money [around $3600]. What about people who just can’t afford these out-of-pocket expenses?"

"A full subsidy and a partial subsidy will be available for people who have low incomes but not low enough to qualify for Medicaid."

"I want one of those," Lisa remarks. "How do you qualify?"

"The full subsidy," Rebecca explains, "is for people under 135% of the federal poverty level. In 2005 this is $12,920 for an individual and $17,321 for a couple. There is also an asset limit of not more than $6,000 for an individual or $9,000 for a couple, and $1,500 for a pre-paid funeral plan. The partial subsidy is for people up to 150% of the poverty level, here the income limits are $14,355 for an individual and $19,245 for a couple. The asset level is 10,000 for an individual and $20,000 for a couple."

"So basically, anyone with their own home is out of luck." I comment.

"No," Rebecca quickly corrects me, "your home and a burial plan do not count in the asset limit."

Lisa, who’s been pondering all of the above, raises the following, "Let’s say Medicare D rolls out, and people have trouble getting the medications they need. Let’s say I can’t get my name brand Coumadin, what do I do? How can you help? At what point should somebody call the Center for Medicare Advocacy?"

"This is all new ground," Rebecca admits. "We haven’t yet assisted people through the appeals process yet because all of this is brand new and not yet in existence. But lets say you’ve applied for the low-income subsidy and been denied, you should call the Center and we will try to work with you through the Exceptions process. Currently our focus is on helping educate people as this unfolds."

"Rebecca," I comment, "everyone thinks about Medicare as being mostly for older Americans. But the truth is that even in CT—the richest state in the country--we have thousands of people with severe disabilities who receive Medicare and Medicaid, in other words they have both significant illnesses and are poor. My understanding is that for these dually eligible people, where their medications were once fully funded by Medicaid, they will now be expected to pay a per-drug co-pay of between $1 to $5."

"That’s correct."

"I find this very upsetting," I say, "that the most at-risk population in the state—the sick and poor—will end up having to pay more under Medicare D. For some, including those with serious mental and medical disabilities such as schizophrenia and severe heart disease, this will be catastrophic. While $1 to $5 per prescription may not sound like much, I know a lot of people who will have to choose between groceries and their medication. It’s a real penny wise pound foolish solution, because going without medication for many people will mean imminent hospitalization, or even more dire outcomes. Is the Center for Medicare Advocacy involved in this issue?"

"We’re currently working with legislators to try to fix this, and we’re doing this as part of a broad coalition of organizations that work with elders and people with disabilities including the Area Agencies on Aging, the AARP and the National Alliance of the Mentally Ill (NAMI)."

At this point Lisa and I have exhausted our questions, although we both know the minute we hang up there will be more. On the plus side, we’re getting a better feel for this issue, on the down side I’m struggling to see the benefit of this new benefit. I’m suspicious that so many companies are throwing their hat in the ring to offer Prescription Drug Plans (18 at last count for the state of Connecticut)—clearly, there’s money to be made here. I worry too about the impact this will have not just on patients, but on their providers and families as people need to figure out which plans cover which drugs. Will doctors have to base their prescribing patterns around an individual’s particular formulary? A shiver runs through me at the thought of needing to stay current with 18 different plans. I envision mountains of new forms and time-consuming processes for appeals. I guess these details will get sorted as this moves forward; at least I hope so. But the one piece of this that needs to be fixed—and fast—is the part that asks the poorest and most-ill residents of this country—the Medicare and Medicaid dually eligible--to foot the bill through co-pays. If this doesn’t happen the "D" in Medicare will not just be the final grade, but for some, whose lives are maintained and prolonged through the use of needed medications, it might well be the "D" of despair and even of death.


If you think that you, or someone you know, might qualify for the full or partial subsidy the "Application for Help with Medicare Prescription Drug Plan Costs" Social Security Form SSA-1020 can be obtained by calling 1-800-772-1213, and it can also be completed online at www.socialsecurity.gov . Click the link entitled, "New Medicare Prescription Drug Plan" and follow the prompts for completing the application.


Resources for information on Medicare D:

The Center for Medicare Advocacy

800-262-4414 and (860) 456-7790 phone

860-456-2614 fax

www.medicareadvocacy.org website



www.medicare.gov website

National Alliance for the Mentally Ill

www.nami.org web site (the Medicare D section is under the link for Public Policy)

1-800-950-NAMI their help line

The Social Security Administration

www.ssa.gov web site