NEW DRUG PLAN Agencies fear coverage loss for 'dual eligibles'



'Dual eligibles' received benefits from both Medicare and Medicaid.
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WASHINGTON -- Some of the nation's oldest, sickest and poorest people could find themselves without drug coverage on New Year's Day if their transition into the new Medicare prescription drug benefit doesn't go smoothly.
Medicare officials, knowing that even a short coverage lapse for any of these roughly 6.4 million people could be life threatening, have automatically enrolled them in the new drug plan to assure that their drug regimens are uninterrupted.
But lawmakers, advocacy groups and a congressional watchdog agency say that may not be enough. They say that untold numbers of these so-called "dual eligibles" -- who receive benefits from both Medicare and Medicaid -- will still fall through the cracks when their drug coverage shifts from Medicaid to Medicare on Jan. 1, 2006. Medicare is the federal health program for the elderly or people with disabilities, and Medicaid is the state and federal health program for the poor.
Concerned officials
"We're certainly concerned," said Christine Bronson, the Medicaid director in Minnesota, where 93,000 dual-eligible beneficiaries reside. "Whenever you make a change this big, perfection is not a realistic expectation."
Some will miss out on the new coverage because of inaccurate enrollment lists, administrative errors and their own confusion about the benefit. Others worry that these clients could be assigned to new plans that won't let them fill prescriptions at their regular pharmacies or cover all their medications.
Preliminary findings from a pending report by the Government Accountability Office say those kinds of "problems will likely arise" because of the complex nature of the Medicaid-to-Medicare shift, which affects all dual beneficiaries at once and provides no transition period or overlap in their coverage.
The draft GAO report concludes that Medicare's "plans are not adequate to ensure, that in all cases, dual-eligible beneficiaries can immediately obtain necessary drugs." That could pose serious problems because they have higher rates of chronic illness, disability, cognitive impairments and other health needs.
Example
Consider Barbara Hunt, a dual-eligible beneficiary from Hamden, Conn., who uses a wheelchair and takes 15 medications each day for pain, fibroids, asthma, osteoporosis, high cholesterol and other ailments.
Hunt, 58, doesn't know if she's been enrolled in a plan and worries that none will cover all her medications. Because of her fixed, monthly $719 income from Social Security Disability Insurance, she can't afford to pay full price for drugs that aren't covered. The $1 to $3 co-pays required under the Medicare coverage will also hurt, she said.
"I am terrified," she said. "It seems on the surface that wouldn't be a hardship, but if you have to pay that every single time you go to the drugstore, that's a lot of money." When her coverage was under Medicaid, all of Hunt's prescription drug costs were covered.
Medicare officials stress that the GAO study is incomplete and that the final version will better reflect the safeguards in place to avoid coverage lapses, said Gary Karr, a Medicare spokesman. Private contractors are checking enrollment data to ensure that no people will go without coverage.
For people who may be overlooked, "we're working on a mechanism where we can capture that person and make sure they can walk out of the pharmacy with their prescriptions and the billing issues will be taken care of" later, Karr said.
Wait for coverage
But some fear that people who become dually eligible late in 2005 could face a one- to two-month wait for coverage. That's because of a time lag between submission to Medicare of monthly state eligibility lists and the time that drug coverage actually takes effect.
"That will certainly be a challenge," said Bronson, the Minnesota Medicaid director. "[Medicare] said they'll try to have some mechanisms in place to bridge those days or weeks, but it's unclear how that will play out for an actual individual."
Any glitches could expose an already vulnerable population to additional hardships. Dual-eligible beneficiaries are disproportionately minorities and women. Many are likely to have poor educations, live alone and have more than two chronic illnesses. They're also more likely to be at least 85 years old. About 23 percent of dual enrollees are in nursing homes, compared with roughly 3 percent of other Medicare recipients.