Dual Eligibles Find Part D Rollout Problem Plagued

Many of the worst fears about the new Medicare Part D prescription drug plan appear to have materialized, at least in the first week of the program.

Throughout the country, the program has endured a tidal wave of complaints including reports that patients were being charged inappropriate copayments, pharmacies were unable to confirm eligibility in the program, and drug plans were failing to have transition policies in effect for the 6 million“ dual eligibles” who ceased having their prescription drugs paid for by state Medicaid programs and began coverage under the new Medicare program on January 1.

So severe were the problems that at press time about half the states and Washington, D.C., had taken emergency action to continue prescription drug coverage under state financing until problems with the new federal program could be fixed.

Psychiatrist Andrea Stone, M.D., told Psychiatric News that problems with the transition have created near pandemonium at the community mental health center where she works in Westfield, Mass. She is medical director at Carson Center for Human Services.

“On Wednesday [January 4] I got my first call about a patient who could not get insulin supplies,” she said. “Then we had an onslaught of patients going to the pharmacy being told they couldn't receive medications or being told they could have their meds but would have to pay $80 or $90.

“Their copayments were much more than they were supposed to be,” she continued. “A lot of our patients can't pay that kind of money.”

Stone also told Psychiatric News that many patients were informed that they needed prior authorization for medications, even though prescription drug plans were supposed to have transition plans for dual eligibles to circumvent the need for prior authorization. In other cases, patients were informed that the pharmacy could not confirm their enrollment in a plan.

“So far it has been stress, confusion, and pandemonium,” Stone said.

She said the problems have been particularly acute for patients being treated with clozapine. Those patients are typically on clozapine because they have not responded to other medications, yet are being told they cannot get their prescription without prior authorization.

“I don't think these [pharmacy benefit] companies understand about severe and persistent mental illness, and I don't think they understand the issues around [clozapine],” she said. “They just don't seem to understand that our patients are not in a position to do all this phone calling and negotiation.”

To ensure that patients continued receiving their medications, Stone said some pharmacies agreed to supply the medications without assurance that they would be compensated. And by the end of the second week of January, some of the problems appeared to be abating, but much still needed to be resolved, she said.

Stone also expressed special appreciation to APA's Office of Healthcare Systems and Financing for its ready attention to the problems experienced in her state. “That office has been invaluable in bringing to CMS's awareness that there is a big problem,” she said. “I've been very impressed with APA's advocacy.”

Irvin (Sam) Muszynski, J.D., director of the Office of Healthcare Systems and Financing, urged psychiatrists to contact the office as they and their patients experience problems with Part D (see box on page 1).

“We had been very concerned that the implementation of the Part D benefit for dual-eligible beneficiaries would be very rocky,” he said.“ That's why we put our monitoring system in place. We can't fix the problems we don't know about.”

Despite reassurances from CMS in the time leading up to January 1, many of the problems that have been encountered since then were predicted not only by mental health advocates, but by the government itself. A December 2005 report by the General Accountability Office predicted that contingency plans by CMS to ensure that beneficiaries receive medications—such as the point-of-sale fail-safe mechanism—would not be implemented in time.

“The complex process for transitioning dual-eligible beneficiaries on a single day with no overlap could create difficulties ensuring that prescriptions for some members of this vulnerable population are filled,” the report concluded. “The success of the transition will largely depend on the extent to which dual-eligible beneficiaries (1) are properly identified and enrolled in PDPs [prescription drug plans], (2) do not have to change their customary pharmacy, and (3) are enrolled in PDPs that cover their medications.”

In Massachusetts, for example, Gov. Mitt Romney directed the state's department of mental health to assume the cost of drugs for beneficiaries unable to receive their medications.

“Given reports about what is happening in pharmacies, Gov. Romney has made it clear that we have an obligation to make certain that MassHealth members receive their medication when they need it,” said state Medicaid Director Beth Waldman. “The complexities of Part D make it a difficult program to implement perfectly. Until the program is operating as expected, we will step in to ensure that none of our members who need medication will walk away from the pharmacy without it.”

There are about 190,000 Massachusetts residents eligible for both Medicare and Medicaid, according to the statement.

Waldman said pharmacies will continue attempting to bill the Medicare Part D plan as the primary payer, but as a fallback they can also bill MassHealth directly. Waldman said her agency will monitor the progress being made by the federal government and will recoup what it spends either from private insurers or the federal government.

In North Dakota, Gov. John Hoeven authorized the state Department of Human Services' Medicaid program to provide an emergency 30-day supply of medications to individuals unable to fill prescriptions through Medicare Part D until January 23, while the federal government and the prescription drug plans resolve their implementation issues.

“Medicare Part D is a federal benefit, but they are clearly having difficulty implementing this new program in a timely fashion,” Hoeven said. “Going without prescriptions is not an option for our seniors and disabled, so the state of North Dakota will step up to ensure that they continue to get their medications until the federal government resolves the difficulties.”

Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness, said the problems described by Stone have been experienced nationwide. He highlighted problems experienced by enrollees in United, the prescription drug plan endorsed by AARP (formerly American Association of Retired Persons).

A spokesperson for AARP confirmed that United has experienced“ database problems” affecting “a couple hundred thousand beneficiaries.”

“This is something AARP is taking very seriously,” the spokesperson said. “It is not isolated to United but is a global problem. We are reporting these problems to CMS, and CMS has instructed pharmacists to fill prescriptions for at least 30 days. People should not be turned away without medications.”

Information on Medicare Part D is posted on a Web site sponsored by APA and other advocacy partners at<www.mentalhealthpartd.org>. The GAO report, titled “Medicare: Contingency Plans to Address Potential Problems With the Transition of Dual-Eligible Beneficiaries From Medicaid to Medicare Drug Coverage,” is posted at<www.gao.gov/new.items/d06278r.pdf>.▪