Seniors Struggle to Sort Through Drug Plan A month after the launch of the Medicare drug benefit program, many seniors find themselves mired in confusion. A new Gallup poll says just 22 percent of those eligible have signed up. Those who want to participate have to sign up by May 15 in order to avoid a penalty on their premiums.
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Seniors Struggle to Sort Through Drug Plan

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Seniors Struggle to Sort Through Drug Plan

Seniors Struggle to Sort Through Drug Plan

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NEAL CONAN, host:

This is Talk of the Nation. I'm Neal Conan in Washington.

Nearly a month since it rolled out, the Medicare drug prescription benefit still faces major problems. The jury is still out on whether these are simple teething pains or signs of something more serious. But right, now the system is characterized by confusion.

Many poor people continue to have trouble getting their drugs at anything like the prices they're accustomed to pay. Over the half the states have stepped in to provide drug coverage for those who've fallen through the cracks during this transition period. And many seniors still struggle to figure out which plan out of dozens is best for them.

The administration says Medicare's new drug benefit is on target to reach enrollment goals, but it does acknowledge some problems, as well. Last week, Secretary of Health and Human Services' Mike Leavitt told state officials that the federal government will reimburse states for bills that they've incurred during this transition period.

Meanwhile, those who want to participate in the Medicare drug plan have to sort through these options and decide by May 15th if they want to avoid a penalty on their premiums.

Later in the program, Eminent Domain is in the Talk of the Nation's Opinion Page this week. In yesterday's De Moines Register, Rox Laird argued that sometimes states need the authority to transfer property from one private owner to another.

But first, an update on the Medicare prescription drug plan. If you have questions about the policy and how it's being implemented, give us a call. We'd particularly like to hear from those of you who've as had experience with this program as recipients, pharmacists, health workers. Our number, 800-989-8255, that's 800-989-TALK. Our email address is talk@npr.org.

Joining us here in Studio 3A is NPR's health policy correspondent Julie Rovner who's been covering this story.

Julie, as always, thank you for coming in for this.

JULIE ROVNER reporting:

My pleasure.

CONAN: What's the biggest problem so far?

ROVNER: Well, I think, clearly the biggest problem is for the six and a half million people who use to get their drug coverage through the Medicaid program for the poor. These are particularly vulnerable people; many of them very old or very disabled, about a million of them are in nursing homes. And they were all switched summarily on one day, January first, from the Medicaid coverage to these new Medicare drug plans. And there have been really innumerable problems.

In some cases, people weren't signed up. They were supposed to be automatically signed up. The federal government had created a contingency plan for that and said if one of these people went to the pharmacy, wasn't in a plan, they can be instantly enrolled in a plan that they'd contracted for and given their drugs. That turned out not to be the biggest problem.

The biggest problem is that they were enrolled in plans, but the plans didn't recognize them as being low-income. So they would get to the pharmacy and they would ask for their drugs. And the pharmacist would say here is your medication. And they use to pay a dollar or two dollars. And they said that will be $250 for your deductible. Which, of course, these people weren't supposed to have to pay.

Now, this was happening to other people were being overcharged but most, many of them were in a position to actually pay for the drugs themselves up front and fight about the reimbursement later. These people clearly weren't, so many of them were walking away without their drugs.

Pharmacists were either, a lot of pharmacists were just fronting them their drugs, were giving people drugs, as the woman mentioned in the intro either for a day or two. Sometimes for a week or two, but obviously, that was going to get old really fast for a lot of pharmacists.

The help lines were swamped. It wasn't just the Medicare lines that were swamped. It was the plan lines that seemed to be the biggest problem. So when Medicare says we've added 4,000 operators, that's well and good, but the plans still weren't answering their phones. And sometimes, a patient would come in and the pharmacist would put it through and it would come back saying yes, this patient is in this plan. But we can't give you this drug and you have to call us to find out why.

So, I think, very much what we're hearing about with these problems have mostly been aimed at these very low-income people. As I say, these were all people who had drug coverage before January first. So these aren't the ones who were really grateful for having new drug coverage.

CONAN: Mm-hmm. So why is it all so complicated?

ROVNER: Computers, or as one woman pointed out, one of the advocates pointed out last week, perhaps Congress should have realized when they wrote the law that switching over six million people on one day that happened to be the Sunday of a holiday weekend wasn't the best idea, which I think compounded problems.

But it was getting all of the computer systems to talk to each other; getting the state to tell the federal government which people had both Medicaid because the states run that program and Medicare. Having the federal government, they were randomly assigning people to the plans, and then having the federal government tell the plans which people those were.

Adding to the problems were a lot of advocates, who did a really wonderful job in November and December, when they discovered that these people had been assigned to plans that didn't cover their drugs, switching them to plans that did. But then what was happening was the switches weren't going through. So it was just sort of a cascade of problems.

CONAN: Time has a way of at least ameliorating computer problems. A month on in, is this getting better?

ROVNER: Well, it depends who you talk to. I think the consensus is that it is getting better to some extent. The backlog of people who switch plans that's getting straightened out. But there are definitely still problems. Every pharmacist that I talk to say it's not as bad as it was but it's still not good.

Then we're going to start to see more some problems that we can already anticipate. For example, plans were supposed to give everybody what's called a transitional benefit. Meaning, the first fill. If you come in in January, if you're taking a drug that we don't cover in the plan that you'll get that drug for presumably a month. Although, that wasn't required, but for some amount of times you can go back to your doctor and either get permission to take this drug or get a prescription for a new drug. You know, to give people time to adjust to shift drugs.

When these transition periods are over, then people are going to go to the pharmacy. And the pharmacist is going to say no, this drug isn't covered. So that's going to be a problem that's been-- there's been some of that because some of the plans haven't been honoring the transition policies. But the ones that have--in the beginning of February you're going to see that.

Then you're going to see the problem, now they've discovered that if you signed up late in the month you're certainly not going to get a card. So it's going to be even though technically you're covered, the first day of the next month, a lot of people won't be in the system yet.

So you're going to have trying to sort out the continuing problems from this month, the problems of the new enrollees for next month, and the problems from people loosing that transition coverage. So were not out of the woods.

CONAN: All Right. If you have questions that are not among those 75 that Julie has already answered, give us a call 800-989-8255, 800-989-TALK. Our email address is talk at talk@npr.org.

And let's begin with Cathy. Cathy is calling us from buffalo, New York.

CATHY (Caller): Hi.

CONAN: Hi.

CATHY: Yes. My brother is handicapped and my mother is an elderly woman, and I moved back to try to take care of the two of them. And so they both were involved in this Medicare changeover. And I have a Ph.D. and I was under the impression that I could just read over the Medicare publication that I received in the mail, which was not the case. There is not enough information in the booklet, Number One. It does not clarify any of these issues.

In the end, I did about 100 hours of research to finally find the plan that was best for my mother and for my handicapped brother. And it was quite a tedious process. Which I was really angry enough about after I was done doing all of this work that I contacted all my legislators and wrote them letters because this was not something simple.

And what it ultimately ended up boiling down to was my brother, who is also a kidney transplant recipient, is on 17 different meds. And we had to take all 17 of those meds, and the person on the other end of the phone had to put them into the computer, and then push enter. And it's not just entering the meds, it entering the dosage of the meds and how often he takes the meds to process the 47 different suppliers to figure out which ones would work for him.

CONAN: And I presume you'd have to go through this all again if he got, oh, slightly better.

CATHY: Well, I don't know about that. But I do know this; that we sat there on the phone putting the 17 different meds in three different times. And each time the person got to the end and pushed enter, the computer crashed.

CONAN: Julie Rovner, is Cathy's story unusual?

ROVNER: No, not at all. I've talked to a lot of Ph.D.'s, a lot of health professionals, a lot of people who have just sort of thrown their hands up at doing this. This is, I think what happens comes into the category of too much of a good thing. When Congress designed the plan, they wanted there to be private competition to compete to hold prices down.

But what happened is that we got an awful lot of private companies that stepped up. That's why we've got so many different plans and so many different drugs covered by the so many different plans. I mean, Medicare officials like to say one size doesn't fit all; this is sort of the antithesis of one size doesn't fit all.

CONAN: Cathy, good luck to you.

CATHY: One more comment.

CONAN: Sure.

CATHY: There was a number that wasn't well publicized that's open 24-7 and you can call that number, and the people are really nice at the other end, and work with them; but this research that I told you that I had to do, part of that process was, in the end, getting to that number.

CONAN: Mm hmmm, and...

CATHY: So, that would be helpful if more people new about that number and that number being available 24-7.

CONAN: Okay.

CATHY: Thanks.

CONAN: Kathy, good luck to you. Bye-bye.

Joining us now is Tricia Neuman, vice president at the Kaiser Family Foundation and director of their Medicare Policy Project. She is also with us here in Studio A.

Thanks very much for joining us.

Ms. TRICIA NEUMAN (Vice President, Kaiser Family Foundation): Thank you for having me.

CONAN: Now another big issue has been enrollment numbers in this program. You've done a study updating enrollment in the Medicare Drug Program. How many people were eligible to sign up when the program began on January 1st, how many people have signed up?

Ms. NEUMAN: That's a good question. So, there're 43 million people on Medicare and the government had assumed that 29 million people would be signing up for the new prescription drug plans. There, at this point in time, 14 million have. So there are 14 million people who are now in these drug plans and there are another 15 million to go; but of these 14 million people, most of them already had drug coverage, so that includes the 6.5 million people that Julie was just talking about.

It also includes people who were in Medicare Advantage plans. They're a little bit more than three million people who we're not sure whether they have drug coverage or not beforehand, who have now signed up.

CONAN: So broadly, the people who have not signed up could be characterized as people who aren't taking drugs right now. They're healthy.

Ms. NEUMAN: No, no, no. These people could be healthy or sick, they just haven't signed up yet. So there are 15 million people who were, an additional 15 million people who were thought to be, were thought would enroll in a Part D plan, and they have yet to do so. They have until May 15th to sign up for a drug plan, but it certainly suggests that there is a lot more to go, in terms of enrollment between now and May 15th.

CONAN: And explanations in terms of people who may be confused and don't know which, if any, of these policies they should sign up for.

Ms. NEUMAN: Right.

CONAN: Okay, and also, the raw numbers are important simply for economies of scale, one would think.

Ms. NEUMAN: That's right. It's important for plans to have enough people sign up in order for them to maintain business. So one question, moving forward, is whether the enrollment will be sufficient to keep all these plans in operation. Though, some people might say it might be just as well if some of them fall out in the next year or two to simplify choices for seniors, but enrollment is important.

It's also enrollment for premiums because the government assumed that there will be robust participation. They thought a lot of people would sign up and they would be healthy and sick. It would be a mixed pool of people. But if sicker people come in first, and not as many people sign up as had been expected, then it's quite possible that average premiums could rise. And so that's another reason why these participation numbers matter.

CONAN: We're going to take a short break. When we come back we'll be joined by an official with Medicare and Medicaid Services and take more of your calls: 800-989-8255, 800-989-TALK. Our e-mail address is TOTN, excuse me, that's the old e-mail address. The new email address is Talk@NPR.org.

I'm Neal Conan, I'll get into this millennium soon.

It's THE TALK OF THE NATION from NPR News.

(Soundbite of music)

NEAL CONAN, host:

This is TALK OF THE NATION, I'm Neal Conan in Washington.

We're talking about the new Medicare Prescription Drug Plan that went into effect on January 1st of this year. Seniors and pharmacists have been wrestling with incorrect membership cards, computer glitches and some states have had to take emergency action to pay for drugs when problems arise using the new Medicare Drug Benefit.

If you have questions about how the plan is working for you, give us a call: 800-989-8255; that's 800-989-TALK. The e-mail address is Talk@NPR.org. Still with us are NPR Health Policy Correspondent Julie Rovner and Tricia Neuman, a vice president at the Kaiser Family Foundation and director of their Medicare Policy Project.

Joining us now from her office here in Washington is Leslie Norwalk, deputy administrator of the Centers for Medicare and Medicaid Services.

Good to have you on TALK OF THE NATION today; we appreciate it.

Ms. LESLIE NORWALK (Deputy Administrator, Centers for Medicare and Medicaid Services): Thanks, Neal.

CONAN: Why have there been so many problems with this?

Ms. NORWALK: Well, it's a gigantic change for the Medicare program. I think a number of different things are happening. One, over six million beneficiaries, as you were discussing earlier, have transitioned from the state Medicaid programs over to the Medicare Program.

And on top of that, tens of millions more are also joining the program either with Medicare Advantage or brand new, and that's millions of people adding to a program. It was not unanticipated that we would have problems. Our hope is that we can resolve them as quickly as possible and start making sure that prescriptions get into the hands of people who need them.

CONAN: Mm hmmm. Now, there were two years to get ready for this, no?

Ms. NORWALK: Well, we did. December 2003 was when it was signed and I can assure you that many, many people have been working diligently to ensure this transition be as smooth as possible. And what I can say is that pharmacists have successfully been filling over a million prescriptions a day. So many beneficiaries are getting what they need at the pharmacy. But, frankly, if one beneficiary doesn't, that's one beneficiary too many and we are diligently working to ensure that every beneficiary can get the prescriptions they need, when they need them.

CONAN: What about those enrollment rates that we were talking about earlier. Does that not present a problem over the longer term?

Ms. NORWALK: I do think that, ultimately, we will end up with a significant portion of the Medicare Program getting the drug benefit. Our actuaries who put together the numbers that Tricia mentioned are very optimistic in their projections. I think that the secretary has been focusing more to a number that is quite a number less actually than what the actuaries had it estimated for purposes of developing the cost estimates around the program.

We think, overall, and this includes people who have creditable coverage, and that's coverage that would be provided through an employer program or the Medicare's often subsidizing that program so that retirees can continue to get their coverage through their old employer or union, and those numbers, we think, in total will look like 28 to 30 million. Or if you take off that employer/retiree piece, it's more like 14 million or so.

CONAN: Mm hmmm.

Ms. NORWALK: We're on track, we've got about 20 thousand or so that are enrolling online and tens of thousands more that enroll everyday with a plan, so we do think that we'll meet the targets that the secretary has described.

CONAN: Wanted listeners to have a chance to talk to you. The number, by the way, if you'd like to join us is 800-989-8255. Talk@NPR.org is our e-mail address.

And let's bring Peggy on the line. Peggy is calling from St. Louis.

PEGGY (Caller): Hi, thanks for taking my call and thanks for your program.

CONAN: Thank you.

PEGGY: I'm a nurse. I work in a cardiology and internal medicine clinic where about 50 percent of our patients are Medicare and a percentage of that 50 percent also has Medicaid. It's been a horrible experience, as a healthcare provider, to try to transition these patients.

The Medicaid patients, who were getting their medicines paid for, now have gone to their pharmacies and they're being told, well, you have a huge co-pay because they've automatically been enrolled into a program, whereas before we had gotten Medicaid prior authorization and they had a very small co-pay. So, I have found that to be a big problem.

The other thing with the elderly patients, some of whom we were getting assistance for through drug company-sponsored programs. Those programs are being discontinued or severely cut back because now there's Medicaid D. Then there's a third population of patients: those who are over 65 who are eligible for Medicare, but are on no medication, like for of my parents. Now they're being forced to pay a premium for the Medicare D as to avoid a penalty in the future.

CONAN: Mm hmmm.

PEGGY: What people need to understand is Medicare, part A and B is a government sponsored, very well run, program.

Medicare D is administered through private companies and it is not like the regular Medicare. And the hours, and I'm not kidding, we have a timer on our phone, over an hour on hold trying to get some information about these Medicaid patients who had prescriptions that are now not being covered.

You know, just my personal experience, you know, and the many people who are going to be now forced to pay a premium who aren't yet on medication. I haven't heard any discussion about that...

CONAN: Mm hmmm.

PEGGY: ...and those premiums are going to insurance companies.

CONAN: Leslie Norwalk, I know you can't help Peggy's individual problems, but some of the systemic questions she's raised.

Ms. NORWALK: Right. She mentioned a number of points that I think are important to discuss. The first one relates to the huge co-pays that she says that many that are dually eligible would have to pay. That relates, I suspect, to one of those systemic problems that we've heard about early this month, which had to do with beneficiaries who are dually eligible, those on Medicaid who are now moving to the Medicare program.

And if they switch their plan later in the month, particularly in December, and we found that in the beginning many of those people, once they were enrolled in a new plan, the information that corresponded with their correct co-payments didn't transfer.

And, so may have been asked if a co-payments frankly that they should have not have been asked to pay. We hope to have rectified most of those situations so that those beneficiaries won't have those sorts of problems and appreciate that it is a big concern.

No dual eligible should ever pay more than $5.00 for a brand name drug or $2.00 for a generic drug. And that's very important; and when those instances occur, people can always call us at 1-800-MEDICARE if they have difficulty getting through their prescription drug plan because the wait time is long.

CONAN: Is that the 24-7 hotline number, 1-800-MEDICARE?

Ms. NORWALK: That's right. So, 24 hours a day, seven days a week, and we've also been working on our call lines to make sure that those wait times are limited and have set up special lines for pharmacists so that when beneficiaries are standing in front of them at the pharmacy, two can get through.

If I could mention, the second issue that Peggy raised relates to Patient Assistant Programs that many pharmaceutical manufacturers have offered over time, particularly to help those Medicare beneficiaries who had no other drug coverage. We have been working closely with many people and certainly, some in industry, to make sure that they understand that there is nothing in the Medicare Program that would prohibit those from continuing and hope to encourage many of them to continue, or as many as possible to continue beyond just because this particular drug benefit is in effect, but to continue in 2006 and beyond.

And we'll continue to work with them, going forward, and are hopeful that they can either provide those to beneficiaries who haven't signed up for the drug benefit, or even if they have signed up, can help for particular drugs that are very expensive because of the high prices of that particular drug.

CONAN: Mm-hmm.

Ms. NORWALK: And then third, she mentioned her parents, and Peggy, I wanted to let you know, one of the important thinks about insurance, and this is true of all insurances, is that you pay a premium. And, typically, those premiums go toward catastrophic costs and the Medicare program is no different. And while many beneficiaries aren't on prescription drugs now, there are options all over the country that are under $20.00 a month and a premium cost, regardless of someone's income.

And for that $20.00, not only do you get regular coverage, but you get the peace of mind knowing that if you have a very expensive drug need, that the Medicare Drug Program will help pay for that.

And once you've spent $3,600.00 out of pocket, 95 percent of those drug costs are covered. And that's, I think that can be really important for people, particularly given the number of prescriptions on the market that can be tens of thousands of dollars a year.

And then finally, I would point out that the Medicare Program does regulate all of the companies that are providing drug coverage just like we regulate those pay claims for Medicare parts A and B, as well as all the providers, whether they be, you know, all of them really are in the private sector. The private sector and the Medicare Program need to work in tandem to make sure Medicare beneficiaries get all of their benefits, including prescription drugs or physician services, or hospital services.

And the Medicare Part D program is an integral part of that, certainly. And we pay very close attention to those companies who are providing benefits to make sure that they are doing it appropriately. But I think Peggy raised some very important points today and I appreciate being able to discuss them.

CONAN: Okay, Peggy we appreciate the phone call. I think Peggy's got off to look for forms or something.

Here's one final e-mail question. We know we promised to let you go, Leslie Norwalk, and we appreciate your time today. There's an e-mail question from Chester Soling(ph): The new drug bill mandates that multiple insurance companies can offer protection coverage in each state. Therefore, each state has different companies with different coverage.

My state has 41 companies offering protection. How will any druggist know what co-pay is required for any covered person and when that person reaches his or her maximum when coverage runs out? With big drug companies, such as Walgreen's, it might not be hard. With individual druggists, this may be almost impossible. In addition, the sales cost by each insurance company to sell coverage with a sales force and advertising adds to the cost of medicines.

But, I guess back on that first point about the, you know, the burden of this on pharmacies.

Ms. NORWALK: Well, that's a terrific question. I would like to thank every pharmacist out there. They really have been on the front lines and heroes, making sure that beneficiaries get the drugs they need during this transition period.

But overall, there are a number of things that we have done to work with pharmacies to make sure that they have the information at their fingertips on a real-time basis. Pharmacies are probably more sophisticated than any other provider type, in terms of dealing with the claims and how much the co-payments are and so forth, for each particular drug benefit. So for the 41 plans in this gentleman's state, for example, every pharmacy has access, and I think over 99 percent of all pharmacies use these computer systems for real-time information...

CONAN: Mm-hmm.

Ms NORWALK:...they've got access to a number of things. The first is something called an eligibility query. So let's say my dad forgot his card when he walked into the pharmacy. The pharmacist could put in his information, like his name, Social Security number and birth date, and find out what plan he's in. And that can take under a second to do and it's all automatic, and then once the plan is determined, again, on an automatic computerized basis, the pharmacist can query the plan, gee, what should the co-payment be for the three or four drugs that my father is picking up that particular week?

And because of that, it, we've put in computer systems here in the Medicare program to do everything from calculate what the payments are, to what the costs would be when you hit catastrophic coverage, and so on and so forth, so it's all electronic because we appreciate that the pharmacy needs to spend time with the patient, not dealing with his claims information. And that's one of the most critical points that we're working on, to make sure that these systems can talk to each other so the pharmacist can do just that.

CONAN: And they do somehow manage to figure out which credit card company to reach to see if our credit card is any good, so yeah, they can probably manipulate these computers pretty well.

Ms. NORWALK: Yeah, there, well, I think, having the systems in place is, you know, really important, so I think that the transition period is going to be critical, just making sure that beneficiaries, particularly if they had different insurance coverage in December, can continue the drugs they're on in January or so, and make sure that the beneficiaries can, if they need to change what they're on for example or there's anything that would be different from a formulary perspective or the drug plan list, that those beneficiaries can work with a pharmacist to get what they need.

And in order for that to happen, the pharmacist needs to spend less time on the phone. So we're working with all of the plans to make sure that those customer service representatives can be responsive and keep the pharmacist in front of the patient rather than on the phone. That's where they need to be.

CONAN: Leslie Norwalk, thanks for taking time out. We know you're very busy. We appreciate it.

Ms. NORWALK: Yes, hopefully busy resolving all of these issues. I appreciate your attention to this, and Julie and Trish are terrific panelists, so I'm sure that they can fill you in as needed.

CONAN: Good luck to you.

Ms. NORWALK: Thanks.

CONAN: Leslie Norwalk is deputy administrator of the Centers for Medicare and Medicaid Services. She joined us from her office here in Washington, D.C. You're listening to Talk of the Nation from NPR New, News...News, that's what it is.

And still with us, as we just heard, are Julie Rovner, NPR's health policy correspondent, and Tricia Neuman, a vice president at the Kaiser Family Foundation, director of their Medicare policy project. And, I don't know, listening to Leslie Norwalk, Julie, do you derive a lot of comfort that these problems are going to be resolved any time soon?

Ms. JULIE ROVNER (NPR Health Policy Correspondent): Well, I certainly derive a lot of comfort, and I think everybody acknowledges that CMS is working very, very hard on this, that Medicare officials have not been sitting around for the last two years getting ready. It's just that this was an enormous project and as several people have pointed out, perhaps making this begin on January 1st when everybody else who has employer-provided coverage tends to change plans, maybe that wasn't the best idea, either. Maybe they should have made it February 1st or December 1st, but I think everybody I've talked to has said that everybody at Medicare has been working extremely hard. This has been an enormous and complicated undertaking.

CONAN: Let's see if we can get another caller on the line. This is Linda, Linda with us from Southern Pines in North Carolina.

LINDA (Caller): Yes.

CONAN: Go ahead, please, you're on the air.

LINDA: Hi. I just wanted to say that first of all, I really do think that Medicare has done a fantastic job on this, considering the millions of beneficiaries that are out there. However, as far as Congress is concerned, I think that they slanted this towards the drug companies because to reach the 22-500 before you hit the gap...

CONAN: That's a deductible?

LINDA:...the deductible, or the amount that you have to pay before you reach the gap, the $2,250, they count not only what you pay, but what the insurance portion pays. So in other words, what they do is they count the full cost of the drug to get to that point, to, to reach the gap or the donut hole. But then, to reach catastrophic, they go back and they only count what you have paid out-of-pocket towards that drug, and I think that's pretty unfair.

CONAN: Bait and switch, Tricia Neuman?

Ms. TRICIA NEUMAN: Well, this was really done for budgetary purposes. When Congress...

CONAN: But, yeah.

Ms. NEUMAN: Right. When Congress went about creating this law, I don't think anybody thought it would be great to have a gap in coverage in a donut hole, which is the portion of the drug benefit that the caller is referring to, so, but because they were constrained by dollars, we have this very unusual benefit where when somebody does have $2,250 in total drug costs, they end up paying 100 percent, the full amount themselves, and that's simply because not enough dollars were put on the table to cover the full freight.

CONAN: Mm-hmm. And what about also the different ways of calculations that Linda's talking about, that in the first run-up, they count the total expenditure and then they go back to what you have paid, so then the donut gap grows bigger.

Ms. NEUMAN: Well, that certainly makes it harder for people to understand because it is talked about in different terms and honestly, when we've heard this benefit described, some people talk total cost, some people talk out-of-pocket cost, and it really makes it hard for seniors to understand the basic benefit. I guess the other point is not every drug plan looks alike, so some have a donut hole, some don't. Most actually do have this donut hole, so there are not only different terms that are used, but also very different designs in plans across the country.

Ms. ROVNER: My favorite new phrase that has entered the jargon is called a troop facilitator, which is, troop stands for 'true out-of-pocket costs' and that's, of course, what the caller is talking about. When you get up to $3600 in true out-of-pocket costs is when the catastrophic coverage begins, so there's now a computer program to do the troop facilitation.

CONAN: Linda, I hope you and I never meet a troop facilitator.

LINDA: Thanks.

CONAN: Thanks very much for the call. We're going to talk more about this when we get back from a short break. Again, if you'd like to join us, 800-989-8255. And we're also going to go onto the Talk of the Nation Opinion Page. This week the issue is eminent domain, an argument in favor. I'm Neal Conan. Back after the break. It's the Talk of the Nation from NPR News.

This is Talk of the Nation. I'm Neal Conan in Washington. Here are the headlines from some of the other stories we're following here today at NPR News.

Exxon Mobil posted record profits today, over $10 billion for the fourth quarter of 2005. That makes over $36 billion for the year. It's the largest annual reported net income of any company in American history.

And some Senate Democrats are making a last-ditch effort to filibuster the Supreme Court nomination of Samuel Alito. Meanwhile, Senator Lincoln Chafee became the first Republican to say he would vote against the conservative judge. Sixty votes are needed for confirmation, and it seems that confirmation is assured, excuse me, I think that's 51 votes are needed for confirmation. You can hear details on those stories, and of course much more, later today on All Things Considered from NPR News.

Tomorrow on Talk of the Nation, as the international community adjusts to the reality of Hamas's win in last week's Palestinian elections, we'll take a look at Hamas, who they are, and what's next for the Palestinian authority and for Israel. Also, John Lewis Gaddis, the Civil War historian, joins us for a look at his new history of the Cold War. That's tomorrow on Talk of the Nation from NPR News.

Today we're talking about government's, the government's Medicare drug prescription, which is off to a rocky start. Our guests are NPR's Julie Rovner, and Tricia Neuman of the Kaiser Family Foundation.

And here's an email we got from Becky in Kansas City: Dear Talk of the Nation, The greatest source of irritation for me is the fact that legislators assume the community pharmacist will provide explanations and answers to patients. We're paid a salary by neither the government nor the private insurance companies, yet we've been expected to be a stand-in insurance agent. CMS, that's the Centers for Medicaid and Medicare Services, has described an eligibility claim that can be submitted at the pharmacy to help determine which plan a patient is enrolled in.

What they fail to mention is that the pharmacy is charged a transaction fee. Not only are pharmacists not being paid for time spent as insurance agents, we're being charged extra fees that will not be reimbursed.

And Julie Rovner, I guess earlier we heard Leslie Norwalk of CMM say that these guys are saints, and some people are objecting to sainthood.

Ms. ROVNER: Yes. I think a lot of this has fallen on the pharmacists, and, you know, a lot of the pharm-, the pharmacists also went to all of these seminars and, you know, got all this new computer software and, you know, there was really a big effort to get the pharmacists ready, and the problem was, they were getting these computer programs ready really at the last minute.

There had really been no, not enough time for testing, and a lot of them didn't work, and that was where the pharmacists were, you know, presented with angry and upset patients and, and, you know, people who would and who wouldn't or couldn't answer the phone and being on call lines for hours. And I think it's hit particularly hard at the smaller pharmacies, at the community pharmacies that don't really have the volume to spread over everything else.

CONAN: Mm-hmm. Let's see if we can get a caller on the line. Hubert, Hubert's with us from Opelika in Alabama.

HUBERT (Caller): Hello.

CONAN: Hi.

HUBERT: Hi, this is Hubert in Opelika, Alabama. My question basically concerns, I'll be 65 on February the 7th. I'm one day short, I guess, on, they're going to take $80, almost $90 when I go on Medicare and Medicaid on the 1st. They're telling me that I should sign up for some sort of program; however, I am not on any prescription drugs.

CONAN: Well, let's see if we can get you some help from Tricia Neuman.

HUBERT: Okay.

Ms. NEUMAN: Well, the one issue you have to deal with is when you turn 65, you probably should think about signing up for a Part D plan. The question is whether you might also qualify for other help, and it may be that you qualify for the low income assistance that's available to people on Medicare.

For people with incomes below roughly $15,000 per couple, for an individual, or $20,000 for a couple, and people with modest assets, there is additional assistance, and it's very much worth looking into because if you do qualify, you would not pay the premium, you'd pay very low co-pays, you wouldn't face the donut hole that we've talked about earlier, and that might be the extra help that you've heard about.

You also, there's also Medicaid, and if you do qualify for Medicaid, you would not pay that $90 premium that you were talking about earlier, which is the Part B premium...

HUBERT: I may be wrong then. Excuse me, I didn't mean, this is A and B.

CONAN: Mm-hmm.

Ms. NEUMAN: Then for A and B, there is that monthly premium, which is about $90...

HUBERT: Yes, ma'am.

Ms. NEUMAN:...which would be deducted from your Social Security check.

CONAN: Yeah. And excuse me, but if Hubert regrettably develops a condition, say halfway through this year that does require him to take some prescription care, can he change the program that he signed up for in Part D to, you know, if his policy, the one he signed up for, doesn't cover the drug he's suddenly on?

Ms. NEUMAN: There's a one-time change that people are allowed between now and May 15th, and general rule. After that, people would stay in their plan until 2007. And then there's an enrollment period that starts in November of this year for 2007. So, once he's in, he can make one change, but pretty much, he stays with that plan for the remainder of the year.

CONAN: Julie?

Ms. ROVNER: This has been a big issue in Congress, where democrats who opposed this program in the first place are kind of hammering at it. And they're walking a fine line because the last time Medicare tried to do a prescription drug benefit back in 1988 it got repealed before it ever took effect. So, they don't want to go that far.

But one of the changes they want to make is either to require that companies not change the drugs that they offer for a year, because after all the companies can change their drugs but the beneficiaries can't change their plans. Or, in the case of this year, there seems to be growing support among Democrats and some Republicans to maybe have this year be one long open enrollment, so that as people get used to it, perhaps they should be able to change either more than once or after May 15th.

The idea, of course, here is that if you don't create a date, you're not going to entice those healthy people to sign up and therefore make the program viable. So it was put in there for a policy reason, but there's concern that there's so much confusion this year that perhaps it would be, you know, the political path of least resistance to open that up.

CONAN: Happy Birthday, Hubert.

HUBERT: Oh, I was just going to say, no, it's in a week or so. My whole point was, I think, then I need to go to, go somewhere and sign up for something.

Ms. NEUMAN: You probably ought to go to your local social security office to ask about the extra help for people with low incomes and begin the process of thinking about a Medicare drug plan by calling 1-800-MEDICARE.

HUBERT: Okay, I this has been one of those run around things.

CONAN: Yep, it...

HUBERT: And I didn't mean it this way. But thank you so much. I love your program. I listen to it all the time.

CONAN: And we'll try not to give you the run around on other subjects. Hubert, thanks very much for calling. We appreciate it.

HUBERT: All right. Thank you. Thank you, bye bye.

CONAN: And, one final question, Julie Rovner. On Tuesday night the President is expected to make new healthcare proposals that also involve private industry more than previous government health programs can. Are the problems that he's encountering with this Medicare prescription problem, are they going to impact his ability to push through whatever that program may be?

Ms. ROVNER: Well, certainly there's a thought that, you know, that moving towards more individual responsibility and more of a role for the private market and less of a role for government and healthcare. It's obviously the theme of what he's going to talk about. For everybody else, the problem this benefit has encountered, which do those two things, they move to more of a private market and they give individuals more responsibility, it, not having gone so terrifically well so far may certainly have an impact as to how policy makers look at the next set of programs that he's going to offer.

CONAN: Julie Rovner, thanks very much for being with us. NPR's health policy correspondent was here in Studio 3A, as was Tricia Neuman. Thank you very much for your time today.

Ms. NEUMAN: Thank you.

CONAN: Tricia Neuman's a vice president at the Kaiser Family Foundation and Director of their Medicare Policy Project, also here with us in Studio 3A.

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