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By Hernan Molina and Karen Ocamb
 Congress passed the program in 2003 as part of the Medicare
Modernization Act, whereby beneficiaries could voluntarily
move into private plans that would pay for a portion of their
prescription medicine. Because the government would be expected
to spend roughly $720 billion over the next 10 years to subsidize
the program, some politicians are re-thinking the plan. President
Bush, however, has vowed to veto any bill that would cut
the benefit.
Implementing the program has been problematic. At a Nov.
8 news conference rolling out an interactive Web site (www.medicare.gov),
expected to be an invaluable tool to help the 43 million
Medicare beneficiaries review their coverage choices, the
Medicare Prescription Drug Plan Finder initially did not
operate properly.
But most importantly, beneficiaries, especially seniors
and people with HIV/AIDS (PWAs) who are currently enrolled
in other plans, do not understand how Medicare Part D works
or if they should sign up. Here is a brief primer.
Starting Jan. 1, 2006, individuals currently covered by
the Medicare insurance program will be able to get their
prescriptions paid for by a new program called Medicare Part
D. Currently, Medicare offers two basic services for those
who are eligible and enrolled in Medicare. Part A covers
outpatient services such as doctors' visits, specialty referrals
and laboratory. Part B, at an additional cost, covers hospitalization
and certain in-patient services.
For years now, seniors and those who live with chronic
diseases and who are covered by Medicare were responsible
for the costs of their drugs, an issue that after much political
debate and wrangling took us to this new prescription coverage.
In the case of people living with HIV, as with other eligible
patients, members will have to choose a prescription plan
that could be part of their existing health plan (Medicare
+ Choice now renamed Medicare Advantage) as an added benefit,
or they could choose separate stand-alone coverage from a
participating provider.
Letters explaining these changes and options were sent
by Medicare to all beneficiaries last month underscoring
the need for immediate action.
Enrollment for the initial phase of the Medicare Part D
Program will commence Nov. 15, 2005, and will end on May
15, 2006. Those who do not enroll by May 15 will either be
randomly assigned (delegated) to a certain program chosen
by the Medicare Administration or face penalties and possible
delays in coverage, which could lead to gaps in treatment.
If you are a patient receiving Medi-Medi (Medicare/MediCal)
or just Medicare Parts A or B, or both, your prescriptions
will now be paid for by Medicare upon signing up for prescription
plan from an approved provider. This new plan benefit is
a government-paid plan run by private, risk-bearing insurance
corporations.
Patients consulted by IN magazine report they have already
received marketing materials from approved Part D providers
or plan sponsors encouraging them to sign up with their programs.
In California, drug plans must offer statewide coverage in
order to be considered eligible providers.
There are several caveats and key requirements for prescription
drug coverage, and the following guidelines will attempt
to shed some light on this new alternative. (For additional
information, refer to the sidebars.)
Key points for new prescription coverage under Medicare:
- Covered drugs must be prescription drugs or biological
products such as insulin. MediCal excludable drugs (those
not covered under MediCal, except for smoking cessation)
and drugs covered by Part A or B cannot be covered. Excludable
drugs are medicines that are not part of the approved formulary
for Medicare recipients because they are not considered "medically
necessary" or their therapeutic value is linked to
purely esthetic reasons, such as Propecia, which is used
to promote hair growth and stop balding. This could also
apply to Viagra, although some PWAs do suffer from erectile
dysfunction (ED), which can be considered a medical problem,
triggering the medical necessity clause.
- Plan providers must cover drugs in each therapeutic
category (anti-HIV meds, anticonvulsants, antidepressants,
etc.) and each class. Plan providers can define what a
class is. For example, a class of drugs could be defined
as a protease inhibitor, a nucleoside analog, and so on.
- All Part D providers must offer basic coverage. The
Medicare Administration has created exceptions for drugs
such as antiretrovirals (also known as HIV meds) so that
formularies (defined drugs lists) include all of the currently
approved HIV meds without delays or obstacles.
- There will be choices to make, as different companies
will offer different levels of coverage above and beyond
what they are required to cover by the Medicare Administration.
- Low-income patients can get extra help and most likely
will not have to pay for premiums, deductibles, or co-pays.
This will depend on the recipients' income and asset estimation.
For more information on this or if you are considered to
be low-income, contact the Social Security Administration
(see sidebar).
In 2006, 19 Part D providers will offer stand-alone prescription
programs and 12 of those will offer these programs with monthly
premiums below $25 per month. While private insurance companies
will provide these services, eligibility guidelines will
have to adhere to regulations established by the Medicare
Administration.
If you receive a Low Income Subsidy (LIS), you will receive
a maximum premium subsidy of $23.25, after which you pay
the difference. If you do not qualify for LIS, you pay whatever
premium your plan charges, from a low of $5.41 to a high
of $66.08
From this point on, several questions remain to be answered
and everyone should keep a watchful eye out for changes.
Some of the pending questions are:
- How will this new Medicare program affect PWAs
currently receiving services through the Ryan White Care
Act?
- How will the program impact the funding of the
Medicaid program or California's MediCal?
- How it will affect those currently covered by
MediCal/Medicare in terms of choice and in the long term?
- IN consulted with Mena Gorre, public affairs manager
for AIDS Healthcare Foundation who expressed concerns about
issues such as cost, continuity and choice.
"Much of AHF's advocacy focuses on escalating drug
costs and so we were alarmed to discover the new law had
no provision allowing CMS [Centers for Medicare and Medicaid
Services] to leverage its purchasing power to negotiate with
manufacturers on drug prices," Gorre told IN. Also "many
patients who will be transitioned to the new drug program
will be ill-prepared to make such an important choice. Continuity
of care is especially critical for persons living with HIV
and AIDS due to complex treatment and the necessity for strict
adherence. As to choice, formularies must take chronic diseases
like HIV and AIDS into account by making the entire array
of treatments available."
Those currently using the HIV drug Fuzeon as part of their
drug regime must pay particular attention to this. Due to
its elevated cost, the CMS has allowed private Part D plan
providers to exercise treatment authorization procedures
like those now used with similarly expensive drugs prescribed
for the treatment of renal illness, diabetes, cancer, and
other diseases. These procedures basically require that individuals
prescribed Fuzeon have exhausted all other (less expensive)
available options first. With treatment authorization requests
(TARs), doctors must submit documentation to plan managers
substantiating why a patient must start drugs like Fuzeon.
This documentation process usually entails medical history,
including laboratory results showing current resistance to
certain medicines, failing CD4s, and lack of other alternatives.
Under normal circumstances, and as part of the entire managed
care health care delivery system, Utilization Review committees
(UR) review TARs and make recommendations for approval of
requests or suggest alternatives. Because there are really
not that many alternatives to currently approved drugs, it
is likely that TARs will be approved without much discussion.
However, patients and doctors should be prepared to encounter
delays and to argue for the approval of certain drug regimes.
CMS has also acknowledged the need to have plan managers
create drug formularies that include all currently approved
HIV meds so that PWAs can access needed drugs, albeit expensive,
and for which there are, in most cases, no generics or cheaper
options.
Adding to the hurdles of having to enroll in a new, complicated
program, are the issues faced by people who are living on
a limited income and who currently receive MediCal with a
share of cost -- the portion of medical care and medicine
costs for which a patient is responsible -- since the AIDS
Drug Assistance Program (ADAP), will no longer cover this
share of costs. The share of cost amounts to a monthly deductible
that is calculated based on the patients' income and assets
and which can be extremely high as it is with some PWAs who
live with family rent-free. Share of cost is also adjusted
yearly or upon significant changes in income, and can go
up or down depending on an evaluation of the recipient's
assets and income level by the MediCal office.
This issue will be especially problematic for those whose
income and assets are limited but whose rent and food are
free through relatives. Social Security Administration and
MediCal take into consideration these in-kind donations (as
indirect income) as part of the calculation of each patient's
share of cost.
According to Phil Curtis, government affairs director for
AIDS Project Los Angeles (APLA), "This change could
deny access to treatment for many people living with HIV/AIDS,
if, as is the case with oral care, the benefit is not provided
through Medicare."
Curtis is also concerned that some people with HIV/AIDS
on very limited incomes may now have to pay monthly premiums
and possibly additional co-payments to get their drugs. ADAP
will help with some, but not all of these new costs. In response
to the anxiety of clients and community members about this
new program, APLA will be conducting free educational forums
on Nov. 16, Nov. 23, and Nov. 30 at Plummer Park in West
Hollywood.
IN attempted to get a response from L.A. County Office
of AIDS Programs and Policy (OAPP) Public Affairs regarding
Part D and to find out if OAPP was planning educational sessions
for the community and for HIV/AIDS service contractors. Calls
were not returned by press time.
As a testament to how complex this new process is, providers
such as Bienestar Human Services expressed their reservations
and fear as to how it will impact the patients they serve.
"At this point we don't know how our clients fit into
the new program," Noe Zuniga, vice president of services
and programs at Bienestar, told IN. "We will be participating
in a number of town hall meetings with various community
groups to get information and then come back and hold our
own forums. Bienestar is concerned what this may pan out
to look like for our target populations, due to the fact
that the majority of folks are low income and immigrants
who access our services as a last resort and rely on such
a system to assist them with their on-going medical care.
We are rapidly trying to get as many of our staff up to speed
so we can convey how the new program will impact our clientele,
without creating more anxiety than there already is."
Pharmacies like West Hollywood-based Capitol Drugs that
cater to an HIV/AIDS clientele are also struggling with this
program that initially seems relatively straightforward.
Ruth Tittle, Capitol Drug's CEO, expressed concerns about
the potential impact the Medicare Part D program will have
on people currently receiving MediCal and for whom ADAP pays
their share of cost.
Tittle also questioned what will happen with those patients
covered by Medicare who are not currently on a drug regime
and who are now being asked to join a drug plan, which will
require them to pay a monthly premium. Tittle said her staff,
who already assist a large portion of Westside and Valley
residents living with HIV, are attending educational sessions
to learn the ins and outs of the program. Several clients
have already contacted the pharmacy or walked in with advertising
materials from different drug plans basically asking Capitol
Drugs staff to figure out what programs they should choose,
she said.
Despite the frustration these changes are bringing upon
service providers like Capitol, however, Tittle said that
companies like Community Care RX (CCRX) will be providing
objective advice to clients as to what plans are better suited
for each individual case. CCRX is a private corporation contracted
by the CMS to provide counseling for eligible individuals
facing an impending enrollment deadline (see sidebar). Tittle
also points out that while patients should not sit and wait
to make a decision, they should not rush into signing up
with whatever program they are offered, as the penalties
will be minor and the implications of choosing a program
that does not suit the patient's need could be worse. For
instance, once a non-low-income patient is enrolled in a
drug plan, he/she cannot switch to a different plan for a
one-year period.
Another pharmacy serving the HIV/AIDS community is Whittier
Goodrich Pharmacy located in East Los Angeles, which is also
trying to sort through the program's complexity. "Patients
are very scared and confused, and my staff is now attending
workshops and educational sessions to be able to inform clients
as to which plan is best for them," Erica Jing, partner-owner
at Whittier Pharmacy, told IN "The biggest challenge
for us is that we are dealing with a population of recently
immigrated and low income people who are not well educated
about the programs and services they receive, much less about
what Medicare Part D will mean for them. It's going be very
difficult and I hope it won't create more problems than what
they're trying to solve".
To make matters worse, CMS information released as part
of the Medicare & You 2006 brochure has been changed,
and some parts of the program explained in that booklet no
longer apply. And while those details are still being worked
out, enrollment deadlines have not changed.
On a brighter note, patients currently receiving services
at AHF who are covered by Medicare or Medicare/Medical, will
now have an additional option for prescription drug coverage
in light of the federal government's recent approval of AHF's
own Medicare Advantage Plan, Positive Healthcare Partners.
According to AHF, Positive Healthcare Partners is the only
AIDS-specific special needs plan nationwide to be approved
by the CMS for the Medicare Advantage program.
People with HIV/AIDS are not the only ones confused by
this new prescription drug plan. "Seniors still are
having a hard time. Seniors still aren't really prepared,
and they're going to need a lot of help to make the choices
they need to make under the law," Dr. Drew Altman, president
of the Kaiser Family Foundation, told the Associated Press
following the release of a survey by the Harvard School of
Public Health about seniors' attitudes toward the plan.
"This was a program enacted as part of a very high-profile,
partisan controversy," said John Rother, director of
policy and strategy at American Association of Retired Persons
(AARP). "And the other thing is, the benefit is not
what people had hoped to see."
"When you look at the people who say they don't plan
to enroll, it's mainly because they already have coverage.
They have coverage through a former employer or through a
Medicare health plan, and that's just great," Mark McClellan,
administrator for the Centers for Medicare and Medicaid Services,
told AP.
It is imperative that people with HIV/AIDS consult with
a benefits counselor as to how these new changes will affect
your coverage and the treatment you are currently receiving,
the providers told IN. This is not limited to just taking
pills but rather being resourceful to face the many challenges
HIV/AIDS can pose, including new regulations and changes
that occur at a moment's notice. Adherence to medications
and continued treatment success will require all patients
to continue receiving their medications without delays and
unnecessarily harmful interruptions. Living a healthy life
with HIV/AIDS means taking an active role in your treatment.
Medicare Plan D Highlights:
Beginning January 1, 2006, Medicare will provide voluntary
insurance coverage for prescription drugs under Part D.
Eligibility: Open to all Medicare beneficiaries, no matter
their income, illnesses, or current drug costs.
Enrollment: To enroll, call Medicare or assigned plan.
Those receiving both Medicare and Medicaid will automatically
be enrolled. Enrollment begins Nov. 15. Those who enroll
by Dec. 31 will start coverage on Jan. 1, 2006. Enrollment
ends May 15, 2006. Those who enroll after that will pay a
penalty and may have to wait.
Co-pays and deductibles: Monthly co-pays average $33 with
a $250 deductible. Low-income patients are eligible for assistance
through the Social Security Administration and may be required
to pay a monthly premium, despite incorrect information in
the Medicare & You 2006 handbook.
Insurance drug coverage: After the deductible, Medicare
pays 75 percent of prescription drug costs -- but it is capped
at $2,250. Individuals are then responsible for the next
$2,850. Medicare will kick back in when the total cost for
drugs exceeds $3,600 and pay 95 percent. This is the "catastrophic
benefit."
Choosing a plan: Plans and co-pays vary. Some plans only
allow coverage of certain drugs and may restrict use of pharmacies.
Nonprofits like APLA and community pharmacies like Capitol
Drugs have people trained to help you decide.
Resources:
Medicare: (800) MEDICARE or (800) 633-4227, www.medicare.gov
Social Security Administration: (800) 772-1213,
www.ssa.gov/prescriptionhelp/
California State Health Insurance Program (SHIP): (800)
434-0222,
www.calmedicare.org/drugs/index.html
The Centers for Medicare & Medicaid Services (CMS)
within the U.S. Department of Health and Human Services:
www.cms.hhs.gov
Hearing Impaired: (800) MEDICARE, TTY: (877) 486-2048
CMS Specific California plans: (800) 434-0222 for local
SHIPs,
www.cms.hhs.gov/map/map.asp#CA
Medicare & You 2006 (pdf):
www.medicare.gov/publications/pubs/pdf/10050.pdf
Mental Health: www.mentalhealthpartd.org
Kaiser Family Foundation: www.kff.org/medicare/rxdrugs.cfm
Community Care RX (CCRX): (866) 684-5353, www.communitycarerx.com
AIDS Healthcare Foundation: (323) 860-5200), www.aidshealth.org
AIDS Project Los Angeles: (213) 201-1600 (main), 213-201-1500
(client line), www.apla.org
Bienestar Human Services: (323) 727-7896, www.bienestar.org
Capitol Drugs Pharmacy: (800) 819-9098, 310-289-1125,
www.capitoldrugs.com
Whittier Goodrich Pharmacy: (323) 722-1010, www.whittierpharmacy.com
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