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Insurers told to fill Medicare plan gaps

/ Source: news services

The Bush administration has told health insurers under contract to the new Medicare drug plan that they must provide a 30-day supply of any drug a beneficiary was previously taking after tens of thousands of people were unable to get medicines promised by Medicare, the New York Times reported Monday.

In a directive sent to all Medicare drug plans over the weekend, the Bush administration also said insurers “must take immediate steps” to ensure that low-income beneficiaries were not charged more than $2 for a generic drug and $5 for a brand-name drug, according to the Times.

The actions came after several states declared public health emergencies, and many states announced that they would step in to pay for prescriptions that should have been covered by Medicare’s new prescription drug program, which started on Jan. 1, the Times said.

Under the program, about 42 million disabled and older people are eligible to enroll in private plans that will subsidize their prescription drug costs.

People who had signed up for coverage found that they were not on the government’s list of subscribers and insurers said they had no way to identify poor people entitled to extra help with their drug costs, the paper reported.

Dr. Mark McClellan, administrator of the federal Centers for Medicare and Medicaid Services, told the Times that ”several hundred thousand beneficiaries who switched plans” in December may have had difficulty filling prescriptions in the last two weeks.

Critics decry program’s complexity

Despite these problems, Medicare is now covering one million prescriptions a day, McClellan said. With the latest corrective actions, “all beneficiaries should be able to get their prescriptions filled,” McClellan told the paper.

About 20 states, including California, Illinois, Ohio, Pennsylvania and all of New England, have announced that they will help low-income people by paying drug claims that should have been paid by the federal Medicare program, the Times said.

“The new federal program is too complicated for many people to understand, and the implementation of the new program by the federal government has been awful,” said Minnesota Gov. Tim Pawlenty, a Republican. On Saturday, he signed an emergency executive order making the state a “payer of last resort” for the out-of-pocket drug costs, the Times reported.

Some advocacy groups say they believe McClellan underestimated the problems.

“We could see the problems coming. We expressed concern, and it was just pooh-poohed. Now, our worst fears have been realized,” said Jeanne Finberg, a lawyer with the National Senior Citizens Law Center, which is based in Oakland, Calif.

'Bureaucratic nightmare'

The problems go beyond technical difficulties, such as when computer databases fail to note that a beneficiary is enrolled in a plan. In some cases, private plans are just not following guidelines established for their participation.

The plans are not issuing emergency supplies as required and they have set up prohibited restrictions on the types of medicine that beneficiaries can get during the first weeks of the program, according to the American Psychiatric Association.

“Relapse, re-hospitalization and disruption of essential treatment are some of the consequences of the bureaucratic nightmare,” said the association’s president, Steven S. Sharfstein. “I commend those states and other jurisdictions that have taken steps to assure that patients receive their medications in a timely manner.”

McClellan said he has directed plans providing drug coverage to make it easier for pharmacists to resolve questions about a beneficiary.

“I’ve been in touch with the health plans today and they are setting up expedited processes for pharmacists to contact a plan without waiting in a long queue. The plans are setting up those systems right now,” he said.

Federal officials say that a surge in enrollments occurred in late December. About 6.2 million low-income people who had drug coverage under Medicaid were automatically enrolled in Medicare drug plans, and some of them have switched to other Medicare plans, the Times said.