Medicare's new prescription drug benefit is off to a rocky start. Dozens of plans, overloaded computers and an entirely new system have left seniors nationwide scratching their heads. The problems are particularly serious for the 6.5 million low-income Americans who get both Medicare and Medicaid — and whose Medicaid drug coverage ended Dec. 31.
Pearl Hewitt is one of them. The 71-year-old resident of Washington, D.C., takes a lot of medicine. "I've got about eight pills," she says. "I'm a cancer patient. I have a heart condition, arthritis."
Hewitt had been getting her drugs through the Medicaid program — at $1 per prescription. She was well aware that coverage was going to end, and she'd need to enroll in a Medicare drug plan by Jan. 1. With the help of her daughter and the Washington, D.C., health insurance counseling program, she enrolled in a new drug plan. And she thought everything was good to go. "They sent me enrollment paper, card, everything," she says.
But when she went to pick up her first prescription, she got a nasty surprise. "They told me $250 deductible, $89 a month and $5 for each prescription," she says. If she didn't come up with $250, she was told, she wouldn't be able to get her medicines.
That information was wrong, however. Those are the costs for people with higher incomes. Low-income patients like Hewitt are supposed to pay no deductible, no premium and no more than $3 per prescription.
It's a problem that's cropping up across the country. Computers are correctly recognizing low-income seniors as being enrolled in Medicare drug plans, but they're not flagged as low-income — and are being charged the regular prices.
Stephanie Altman, staff attorney with Health and Disability Advocates in Chicago, says that effectively cuts them off from their drugs. "People are walking out of the drugstore in tears, maybe they don't have a credit card or someone to borrow from, or the pharmacist won't put it on credit," she says.
It's putting pharmacists in a difficult situation, says Tom Clark of the American Society of Consultant Pharmacists. "The pharmacy personnel are concerned that they may not get correctly reimbursed for the medication. And they may not be able to bill and get reimbursed later, after the medication is dispensed," he says.
That was the situation for more than 150 patients from the Peninsula Community Mental Health Center in Port Angeles, Wash. After caseworkers spent hours last fall painstakingly matching each Medicaid patient to a drug plan based on his or her specific medications, every pharmacy in town refused to provide the drugs at the reduced prices, says center staffer Susan Flippin.
"In most instances the pharmacists were online for hours, on hold, trying to get information from Medicare," Flippin says. "They had no other resources available to them to contact other than Medicare itself. So they were turning patients away, in some cases giving them two to three pills to get them by."
And going without drugs is perilous not just for those with heart disease or diabetes, but also for those with serious mental illness, she says. "Clients who were stable on medication, should they go even a few days without their medication, were at risk of hospitalization.
Pharmacist Tom Clark says overcharging low-income beneficiaries isn't the only problem with the rollout of the new benefit. During this first month, plans are not supposed to be enforcing rules that require special permission for certain drugs or making patients try cheaper medications first.
But many plans are enforcing those rules, he says. "There was one situation over the weekend where a nursing home had an outbreak of influenza, and the Part D plan was imposing restrictions and not allowing the pharmacy to bill for influenza medications," Clark says.
Medicare and Medicaid administrator Mark McClellan says that will not be allowed to continue. And he says that plenty of help is available, both from the plans themselves, and from operators and caseworkers at Medicare's toll-free hotline, 1-800-MEDICARE.
"We have lots of systems set up to work with states, to work with advocacy groups, to work with beneficiaries and their caregivers, to help people connect with their coverage if they're having any difficulties," McClellan says.
In fact, McClellan adds, the program is now filling more than a million prescriptions per day, and problem reports are diminishing.
But at least six states have started to use their own money to cover drug costs for low-income beneficiaries who are having problems; another three states are considering similar action. And two members of Congress — Rep. Ben Cardin (D-MD) and Sen. Frank Lautenberg (D-NJ) say they will introduce legislation to reimburse those states when Congress reconvenes later this month.