Washington, DC – With continuous reports that seniors and people with disabilities have not had their prescriptions filled as they transition from Medicaid to Medicare under the new prescription drug program, Senate Democratic Leader Harry Reid and Senator John D. Rockefeller were joined by members of the Democratic caucus in a letter to Secretary Michael Leavitt expressing their concerns. The Senators posed a series of questions to the Secretary about the treatment of dual eligibles and urged him to fix gaps of coverage for these individuals. The text of the letter is pasted below:
January 13, 2006
Secretary Michael O. Leavitt
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Secretary Leavitt:
We are writing to express our serious concerns about implementation of the Medicare prescription drug benefit, particularly for low-income seniors and individuals with disabilities. Over the last two weeks, we have heard from Medicare beneficiaries in our respective states and throughout the country who have been denied or delayed access to the Medicare prescription coverage they were promised. Such gaps in coverage can lead to devastating consequences for our seniors, who are often taking multiple prescriptions to manage one or more chronic conditions. We want to know why so many of our constituents have fallen through the cracks during implementation of the Medicare prescription drug benefit, and we urge you to take immediate action to correct the problems.
Last year, the Centers for Medicare and Medicaid Services (CMS) repeatedly assured Members of Congress that the kinds of access problems dual eligibles are currently experiencing would not happen because CMS had taken all the necessary steps “to ensure full-benefit dual eligible beneficiaries will get the prescription drug coverage they need as of January 1, 2006.” Because of CMS’ refusal to admit potential problems with the transition of the dual eligibles to Medicare and the unwillingness of Senate Republicans to support proactive Democratic legislation which could have addressed these problems, our seniors and residents with disabilities are now experiencing undue hardship and distress.
As you are well aware, dual eligibles are among our nation’s most vulnerable populations. They are disproportionately women and minorities and live alone or in nursing homes. Over half of all elderly dual eligibles are limited in activities of daily living and, in comparison to other Medicare beneficiaries, they are much more likely to have heart disease, pulmonary disease, diabetes, or Alzheimer’s. Access to prescription drugs is not an option for these individuals.
The types of coverage barriers dual eligibles and other low-income beneficiaries are experiencing are simply unacceptable, particularly since advocates and Members of Congress tried for nearly a year to work with the Administration to prevent such harmful events from happening in the first place. Despite our extreme dismay that effective fail-safe mechanisms were not put into place to address the transition of the dual eligibles, we are more interested in what can be done right now to quickly alleviate the prescription drug access problems our elderly and disabled constituents are experiencing. We respectfully request your timely response to the following questions to inform our decision-making going forward.
We have been told that approximately 200,000 dual eligibles who proactively selected a prescription drug plan different from the plan they were automatically enrolled into are not being treated as dual eligibles by those plans. Because the plans they selected are treating them like other Medicare beneficiaries, they have been subjected to monthly premiums, the $250 deductible, co-pays higher than $5, and other cost-sharing. Why weren’t the plans that these duals switched to notified that they were duals? What is CMS doing to identify such duals and address this problem? How will duals be automatically reimbursed for costs they incorrectly incurred?
It is our understanding that, in auto-enrolling full dual eligibles, CMS relied on data from the Social Security Administration (like the resident’s home of record) and used that data to randomly assign beneficiaries to plans. In some cases, long-term care residents were assigned to a plan outside of their region because their home of record was in a different state from their long-term care facility. How does CMS plan to address this problem?
We have also heard from nursing homes that billing for prescription drugs has been complicated by delays in uploading data to the national database used by long term care pharmacies. Beneficiary data, when present, has been incomplete or outdated. How is CMS fixing this problem?
Why were the eligibility databases for dual-enrollees not complete and verified by the January 1, 2006 rollout date? Please provide the timeline for identification of dual-eligibles, their medication needs, database creation and population, and quality assurance. What barriers were encountered to completing this process on time? What process is CMS currently using to examine and correct deficiencies in the database so that duals previously unenrolled in a prescription drug plan get the drugs they need?
What steps has CMS taken to educate chain and independent pharmacies about the point-of-sale system? How many chain and independent pharmacies nationwide, including local and independent pharmacies, are utilizing the point-of-sale system as of today, January 13?
Why have some duals, including those with proof of enrollment in both Medicare and Medicaid, been turned away from chain and independent pharmacies without their prescriptions even though the point-of-sale system is in place?
Press reports and pharmacists in our states indicate that the prescription drug plans are not providing the beneficiary data that pharmacies need to file claims and get paid. What is CMS doing to address this problem?
How will pharmacies that have dispensed prescription drugs to dual eligible beneficiaries to meet their needs until coverage issues are resolved get reimbursed (particularly since some plans are not honoring the one-time fill included in their transition plans)?
What strategies have been identified to reimburse pharmacies for the additional time required to properly identify and dispense medications to Medicare beneficiaries experiencing problems with plan enrollment and prescription drug coverage?
Prescription Drug Plans
Prior to plan approvals in April of 2005, prescription drug plans were required to submit an application to CMS that included a transition plan for dual-eligibles who experienced problems with medication access while moving from Medicaid to Medicare prescription drug coverage. Some plans implemented only three-day temporary supplies, despite expectations that plans would offer at least 30 days of transition medications. Why was the implied 30-day supply not a requirement for plan participation? Please provide us with a copy of the transition plan for each prescription drug plan.
On a state-by-state basis, how many plans are actually executing the transition plans they agreed to establish? What type of oversight process has CMS established to address those plans that have not adhered to the agreed upon transition process?
Were pharmacies notified of the transition processes in place for each plan? If so, were they notified of how to access these processes (i.e., using override codes and the like)?
How many plans are employing prior authorization and fail first policies against duals?
The formularies listed on CMS’ website could be changed by the drug plans up until December 30th. This means that if an individual signed up for a plan December 10th and didn’t re-visit to ensure that the formulary to their plan remained the same, it is very possible that an important drug of theirs is no longer covered by the plan. Will CMS require plans to cover these drugs until the beneficiary is able to receive coverage from a different plan?
Are any plans being put in place to assist duals who received a temporary prescription because their drug was not covered under the plan they have been enrolled in (i.e., informing them that they can switch plans or appeal non-coverage and assisting them with these processes?).
What has been done by CMS to make sure that Medicare Advantage plans were aware of dual eligibles?
How many beneficiaries have been enrolled in the WellPoint plan at the point-of-sale?
Based on CMS’ data, how many dual eligibles nationwide have experienced problems getting their prescription drugs? What are the state-by-state numbers?
How many dual eligibles nationwide have been incorrectly charged premiums, deductibles, and/or co-payments? What are the state-by-state numbers? How will they be reimbursed?
What is the average wait time for beneficiaries calling 1-800-MEDICARE? What is the average wait time for beneficiaries calling the prescription drug plans, by plan?
What training have the customer service representatives at CMS and at the prescription drug plans received?
How many beneficiaries eligible for the low-income drug subsidy are still waiting for their Medicare letters and/or cards? How are they supposed to get their prescription drugs filled while they wait?
How many states are currently using state-only funds to cover the prescription drug costs of dual eligibles? How does CMS expect these states to get reimbursement from plans since the Medicare plans have no contractual obligations to the states? How will CMS reimburse states that are providing temporary, emergency funding to pharmacies?
What is the timeline for enrollment? How does CMS intend to insure that a beneficiary who changes plans on the 31st of the month will be able to access their drugs on the 1st of the next month? This turnaround time clearly didn’t work in January, how will it work in subsequent months?
How long does CMS estimate it will take to address the access problems dual eligibles and other low-income beneficiaries are experiencing?
We know you have a strong interest in improving access to the Medicare drug benefit for all Medicare beneficiaries. We, therefore, urge you to take immediate steps to eliminate the coverage gaps that exist for low-income seniors and individuals with disabilities desperately trying to get the prescription drugs they need. We also urge you to work with us to address the problems that require specific legislative remedies. Thank you for your prompt attention to this request.
John D. Rockefeller