Low Income Health Advocate Alert

December 9, 2005

 

This Alert contains Medicare Part D briefings on issues of immediate interest to Medi-Cal and Medicare advocates working with dual eligibles (those on Medi-Cal and Medicare) and other low-income Medicare beneficiaries. 

 

Please circulate to everyone in your office and others who provide assistance to low income seniors and individuals with disabilities.

 

Medicare Part D, the new prescription drug benefit continues to be a morass of complexity, confusion, and potential looming crisis for low-income dual eligibles (those on Medi-Cal and Medicare) and the advocates who assist them.  Dual eligibles will lose Medi-Cal coverage of most drugs starting January 1, 2006. This Alert seeks to inform California advocates of the latest developments. 

 

Note: More information on Medicare Part D, including past Alerts, can be found at the www.nsclc.org website, at www.cahealthadvocates.org/cmc/index.html, and at the websites of organizations listed at the end of this Alert.

 

Key Dates:

 

November  2005 – December 31, 2005:  Dual eligibles are assigned to Medicare Part D plans, effective January 1, 2006.

- Dual eligibles randomly auto-assigned to Medicare Part D plans (PDPs) received a yellow-colored letter sent by the Center for Medicare and Medicaid Services (CMS) earlier last month.  Random assignment carries no assurances that needed drugs or convenient pharmacies are accessible to each individual.  They may choose a different plan, changing plans as many times as they wish.  Changes made by 12/31/05 will take effect 1/1/06.  (Note:  Dual eligibles have a continuous enrollment period and may also make changes after 1/1/06; any change will take effect the first of the following month.)

-Other dual eligibles in Medicare Advantage (MA, formerly HMO) programs were assigned to the prescription drug plan related to the MA (MA-PD plans).  They may face MA premiums (see details below).  They may also change plans. 

 

November 15, 2005 – May 15, 2006:  All Medicare beneficiaries may enroll in a Medicare Part D plan.  (See Update: Retirees, below for more on the 12/31/05 key date relating to potential loss of retiree benefits affecting some individuals with retiree coverage, including some dual eligibles).

 

Ongoing:  California’s Department of Health Services (DHS) will continue to send out notices to dual eligibles whose Medi-Cal drug coverage is ending.  (See DHS Notices, below).  CMS will continue to auto-enroll dual eligibles into Part D plans (as individuals become newly eligible for Medicare or Medi-Cal).

 

January 1, 2006:  Medi-Cal prescription drug coverage for most drugs ends for dual eligibles.  Medicare Part D private plan prescription drug coverage begins.

 

Unknown:  The online CMS Prescription Drug Finder tool (at www.Medicare.gov) continues to be incomplete (e.g., not all drugs covered by plans are listed yet) and at times has included erroneous information (e.g., pricing information).  CMS has been unable to state a date when the formulary finder tool will be complete and accurate, despite the fact that individuals are already choosing an d enrolling in plans.  CMS acknowledged in November that some information was wrong, and the CMS website now includes a disclaimer.

 

DHS Notices to Dual Eligibles:

 

DHS has several notices, including a “Notice of Action: Reduction of Benefits” that will go out this month:

1.      Notice of Action: Reduction of Benefits Notice:  DHS has announced that it plans to send this notice out to all dual eligibles starting December 14.  This notice will be translated into 12 languages, and sent to more than 1 million dual eligibles.  A copy of this notice is available at http://www.nsclc.org/news/05/12/partdCA_dhsnotice.pdf and http://www.nsclc.org/news/05/12/partdCA_dhsnotice2.pdf. 

 

Note:  The final notice is slightly different from an earlier draft circulated last week.  The notice includes the following: If you are a full-scope Medi-Cal beneficiary, Medi-Cal will pay for a 100-day supply of your Medi-Cal covered prescription drugs as long as your doctor provides you with a prescription for the 100-day supply and your pharmacist fills the prescription on or before December 31, 2005.

 

2.      Notice for Medicare Managed Care: Medi-Cal also sent out a notice to those in Medicare Managed Care that Medi-Cal will not longer pay for Medicare Advantage (HMO) premiums.  This notice is available at http://www.nsclc.org/news/05/12/partdCA_dhstermletter.pdf.  This topic was covered in the November 10, 2005 Alert, available at http://www.nsclc.org/news/05/11/partdCA_alert111005.htm.  (See related information on Kaiser Permanente Medicare Advantage, below.)

 

Medi-Cal is also sending out two other notices:

 

3.      Letter to dual eligibles with partial Medi-Cal eligibility: DHS will also send out a notice to approximately 800 individuals receiving limited Medi-Cal (e.g. emergency services), who were not auto-enrolled, encouraging them to sign up for 1) a Medicare Part D plan, and 2) the Low Income Subsidy.  The letter will be translated into 12 languages.  These individual will also receive a Notice of Action: Reduction in Benefits letter (see above).  A copy of this letter is available at http://www.nsclc.org/news/05/12/partdCA_dhspartialduals.pdf.

 

4.      Informed Decisions Letter: As previously announced, DHS planned to send out a customized letter to each non-Medicare Advantage dual eligible, listing potential plan choices by taking into account each beneficiary’s actual drug usage and pharmacy access issues.  DHS has stated that this letter is delayed owing to a lawsuit against Informed Decisions, the independent party producing the letters.  DHS estimates that this letter will not go out until the 4^th week of December at the earliest.  

 

 

CMS Contingency Plan for Dual Eligibles:

 

On Thursday, December 1^st, the Center for Medicare and Medicaid Services announced an additional process to assist dually eligible individuals who fall through the cracks and do not get enrolled in a Part D plan as of January 1, 2006.  This new Point-of-Sale Facilitated Enrollment process will permit an individual who has not been auto-enrolled in a plan to obtain a prescription at the subsidized amount ($1 - $5 per prescription) at the pharmacy.  The individual must have evidence of Medicaid (e.g., Medicaid card, or previous history of Medicaid billing with the pharmacy) and be eligible for Medicare.  Once it is verified that the individual is a dual eligible not in a Part D plan, s/he will be enrolled in a Wellpoint (Wellpoint is a national prescription drug plan).  For more information on this new process, see: http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_adp.php?p_faqid=6248 and http://www.cms.hhs.gov/media/press/release.asp?Counter=1736.

 

Part D Excluded Drugs: Drugs That Dual Eligibles Can Still Obtain From Medi-Cal

 

Although Medi-Cal will not provide dual eligibles with drugs that  are covered by Medicare Part D (even if an individual’s Part D plan does not cover a needed drug), Medi-Cal may continue to provide drugs that were excluded from Part D.  CMS has just posted information about excluded drugs by state.  To obtain the listing of drugs Medi-Cal will cover, go to http://www.cms.hhs.gov/medicarereform/states/optdrugcov.asp.

 

Resources

 

Various Part D materials, including memos on the Low-Income Subsidy and Appeals, detailed  Appeals flowcharts, and past Alerts, are available at www.nsclc.org.

 

California Health Advocates and the Medicare Rights Center have drafted an issue brief concerning the lack of adequate protections for beneficiaries with respect to Part D enrollment and disenrollment issues, available at http://www.cahealthadvocates.org/advocacy/2005/1130.html.  

 

Information for Limited English Proficient (LEP) Clients

 

Special toll-free numbers are now available for speakers of Chinese (Cantonese & Mandarin), Korean, and Vietnamese. This is important because 1-800-Medicare assistance is only available in English and Spanish. This toll-free hotline is being made available by the National Asian Pacific Center on Aging (NAPCA).  Chinese: (Cantonese & Mandarin) 1-800-582-4218; Korean: 1-800-582-4259; Vietnamese: 1-800-582-4336; English: 1-800-336-2722.  If the lines are busy, the caller will be referred to the voice mail. They should leave a call-back number.

 

In addition to 1-800-Medicare, the National Alliance for Hispanic Health has created a bilingual hotline to assist Spanish speaking individuals.  The hotline is available Monday - Friday from 5:00 AM - 3:00 PM Pacific Time at 1-866-783-2645. 

 

The CMS online Prescription Drug Plan Finder is available in Spanish.  You can access it at http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/MPDPFIntro.asp?language=Spanish&version=default&PDPYear=2006&MPDPF_MPPF_Integrate=N&browser=Firefox%7C1%7CWin2000&defaultstatus=0&pagelist=Home&ViewType=Public&MAPDYear=2006.   Note:  See caveats below.

 

A new report, “New Medicare Drug Plan Fails to Provide Meaningful Price Discounts,” prepared for Representative Henry Waxman by the U.S. House of Representatives Committee on Government Reform is available at http://www.nsclc.org/news/05/12/partd_medicaredrugpricing.pdf.

 

Update: Choosing a Plan

 

This Alert contains additions to the information previously provided in the November 10, 2005 Alert.  The previous alert covers this general topic in more thorough detail, see http://www.nsclc.org/news/05/11/partdCA_alert111005.htm.

 

Although the CMS Medicare Prescription Drug Plan Finder and the Medicare Formulary Finder  (both at www.medicare.gov) are potentially the most important tools for comparing and choosing Part D plans, they are still incomplete, and at times, inaccurate.  Further, pricing information on drugs and premium costs can fluctuate.  CMS has been unable to provide a date when formularies will be incomplete.  Users of these sites should be warned that drug information may change.  In particular, drugs which show as not covered by plans may later show as covered.

 

Stories are also plentiful of individuals getting incorrect information from 1-800-Medicare operators.  Some operators do not provide complete and accurate information; others try to be helpful, and guess, providing inaccurate information.  You may wish to let clients know that the 1-800-Medicare number can be unreliable and advise them to write down operator’s names as well as dates and details of conversations if key information is obtained and relied upon.  Please send problem stories to NSCLC using the form provided at: http://www.nsclc.org/news/05/11/partd_stories.htm.

 

Drug plans are doing extensive marketing and telephone agents are motivated to lure individuals to sign up for plans.  Drug plan agents often do not know much about specific details of Part D plans.  Consumers should be warned to beware of heavy-handed marketing and relying on incorrect information; they should keep written records of “promises” made by drug plan representatives (include date, time and details, including promises made, as well as name of agent).

 

Update: Medicare Advantage (HMO) Premium Payments: Kaiser Waives Premium

 

In the last alert, we announced that DHS will cease paying premiums for low-income individuals in Medicare Advantage (“MA”, formerly known as Health Maintenance Organization or HMO, or Medicare Part C) plans, as of January 1, 2006.  Last week, Kaiser Permanente announced it will waive Kaiser Medicare Advantage premiums for dual eligibles for 2006.  This waiver of premiums will assist approximately 2/3 of the 35,000 California dual eligibles who would otherwise face premiums in 2005.

 

Individuals in other Medicare Advantage plans will still face Medicare Advantage premiums in 2006.  As of the date of this alert, we have not heard of any other Medicare Advantage organizations planning to waive premiums.  DHS has provided statistics by county and Medicare Advantage plan of individuals affected.  You may obtain this information at http://www.nsclc.org/news/05/12/partdCA_dhsstats.pdf.

 

 

Update: Retiree Drug Coverage Deadline for Some Retirees is 12/31/05

 

Among the myriad of extremely complex issues surrounding Medicare Part D are the retiree drug coverage issues.  Individuals with retiree medical coverage who are automatically enrolled in Medicare Part D plans (which include 1) all dual eligibles, and 2) all individuals – of any income - in Medicare Advantage plans with drug coverage) are at risk for losing retiree coverage if they do not disenroll from inappropriate plans by December 31, 2005.  In a recent call between CMS officials and state Medicaid officials, CMS stated that it had no power over employer plans who might drop retiree medical coverage for individuals who sign up for (or are auto-enrolled in) Part D plans.  Any effort to retain retiree coverage could come only from individual employers.  Note:  Retiree plans differ greatly; not all plans will drop individuals on Part D; each retiree should look at the letter from his/her employer about Part D coverage. 

 

Example 1:  Mr. Smith is on Medicare and Medi-Cal, and lives in a nursing home.  He has retiree drug coverage from Company X.  Company X provides “creditable coverage,” and has indicated to Mr. Smith that that if he signs up for Part D coverage elsewhere, he will lose his retiree medical coverage (not just prescription drugs but all retiree medical coverage).  As a dual eligible, Mr. Smith will be will be auto-enrolled in a Part D plan without regard to his retiree drug coverage.  If he does not disenroll from the Part D plan by December 31, he will lose the Company X coverage.

 

Example 2:  Mrs. Lee has Medicare and the same retiree coverage from Company X.  Although she is not on Medi-Cal, she is on HealthNet, a Medicare Advantage plan (MA) which is unrelated to her retiree coverage.  (She joined because her retiree coverage still leaves her with a lot of out-of-pocket costs, and in her county, there is no premium for HealthNet in 2005).  Mrs. Smith’s HealthNet coverage includes drug coverage.  She likes to get her prescription drugs through her retiree coverage, however, as she can get brand name drugs at a cheaper price.   Mrs. Smith will be auto-enrolled for 2006 in a HealthNet plan with prescription drug coverage (MA-PD).  If she does not disenroll from this plan and choose a HealthNet (or other) plan with no drug coverage, Mrs. Smith will also lose retiree medical coverage in 2006.

 

Retiree coverage can vary greatly and not all plans are like Company X; also, many retirees do not join Medicare Advantage plans that are unrelated to their direct retiree coverage.  Nonetheless, the scenarios above will affect many individuals.  Depending on actual medical and drug needs, the appropriateness of various plans for particular individuals may vary.  An employer’s notification of the plan’s relationship to Medicare Part D can be found either in an individual letter, or in general correspondence sent to all retirees (e.g., a newsletter).  Retirees can contact their employer’s benefits administrator for another copy or for more information.

 

Update: First Lawsuit on Medicare Part D and Dual Eligibles Filed

 

On Monday, November 14^th, 8 organizations filed suit in federal district court in Manhattan, seeking injunctive relief for dual eligibles (individuals on Medicaid and Medicare) who may otherwise fall through the cracks in the transition from Medicaid to Medicare Part D prescription drug coverage that will occur January 1, 2006.  The lawsuit seeks an order that the government will ensure that individuals do not lose access to medications because of the Part D implementation.  Plaintiffs include several organizations throughout the U.S., including the Congress of California Seniors and the Medicare Rights Center. A copy of the press release and complaint are available online at: http://www.medicarerights.org/pressrelease2005_29frameset.html.

Client Stories Needed: 

 

NSCLC is attempting to focus greater attention on the impact of Medicare Part D on low-income seniors and individuals with disabilities.  Please help us by identifying and sharing client stories and contacts.  We need provider stories and clients who are willing to speak directly with the press or are willing to have the facts of their situation shared.  Please use the form available at http://www.nsclc.org/news/05/11/partd_stories.htm.

 

NSCLC Oakland is Moving

 

As of December 17^th, 2005, NSCLC Oakland is moving.  The phone and email will remain the same.  The fax number and address will change.  See below for updated information.  Thank you in advance for your patience with NSCLC Oakland during the move. 

 

More information about Medicare Part D is posted on www.calmedicare.org, and on main page and California page of the NSCLC website, which you can view at www.nsclc.org.  We will continually post new training materials as this program develops.  Other helpful websites: Center for Medicare Advocacy at www.medicareadvocacy.org; Health Consumer Alliance at www.healthconsumer.org; Families USA at www.familiesusa.org; Medicare Rights Center at www.medicarerights.org; California Health Advocates at www.cahealthadvocates.org; California HealthCare Foundation at www.chcf.org/topics/healthinsurance/drugbenefit; Health Assistance Partnership at www.healthassistancepartnership.org;  and Kaiser Family Foundation at www.kff.org/medicare.

 

 

For more information call or email NSCLC or CHA:

 

National Senior Citizens Law Center

Katharine Hsiao

Khsiao@nsclc.org

Jeanne Finberg

Jfinberg@nsclc.org

 

Until December 17, 2005:

405 14^th Street, Suite 1400

Oakland, CA 94612

510 663-1055

510 663-2028 (fax)

 

After December 17, 2005:

1330 Broadway, Suite 525

Oakland, CA 94612

510 663-1055

510 663 1051 (fax)

 

California Health Advocates

David Lipschutz

dlipschutz@cahealthadvocates.org

3435 Wilshire Blvd., Suite 2850

Los Angeles, CA 90010

213 381-3670

213 381-7154 (fax)

 

 

 

This ‘Alert’ is provided by the National Senior Citizens Law Center in partnership with California Health Advocates as a part of the

California Health Advocates’

 “Medicare and Medi-Cal Community Education and Advocacy Project”

with support from The California Endowment