Testimony of Robert M. Hayes
President, Medicare Rights Center
United States House of Representatives Committee on Ways and Means
Implementation of Medicare Part D Prescription Drug Benefit
June 14, 2006
The Medicare Rights Center appreciates the opportunity to submit testimony to the first oversighthearing on the Medicare Part D prescription drug benefit held by the full Committee on Ways andMeans. This hearing is long overdue.
Staff and volunteers at the Medicare Rights Center have spent the last six months fighting to getpeople the medicines they need under the Part D benefit. If you look at the roll out of Part Dwithout a political or ideological agenda, you will see that many people have been hurt by thestructure of this benefit and by the implementation of the benefit by the Administration and itsinsurance company collaborators. You will also see that countless people are paying lower costsfor medicines that they need. We, and many others around the country, have worked andcontinue to work to ensure that the poorest Americans receive the financial help that is their rightunder Part D. Sometimes we were able to help; too often we were not. We work in the trenchesday in and day out helping people with Medicare who face problems with the system. There havebeen too many problems with the Part D program to list, but we have learned valuable lessonsduring these first months of the Part D benefit and it is those lessons that we will share with theCommittee.
The Medicare Rights Center is a not-for-profit consumer service organization, with offices in NewYork, Washington and Baltimore. It is supported by foundation grants, individual donations andcontracts with both the public and private sectors. We are consumer driven and independent,relying on a small staff and hundreds of deeply committed volunteers to carry out our mission. Weare not supported by the pharmaceutical industry, insurance companies or any other specialinterest group. Our non-partisan mission is to serve the 43 million men and women with Medicare.
Through national and state telephone hotlines, casework and professional and public educationprograms, MRC provides direct assistance to people with Medicare from coast to coast. Each year,the Medicare Rights Center receives over 80,000 calls for assistance from people with Medicare.
Our counselors are trained to assist consumers with complex problems and we complement thebasic services offered by the 1-800-MEDICARE hotline operated by the Centers for Medicare andMedicaid Services (CMS). Indeed, for a number of years 1-800-MEDICARE has been the largestsource of referrals to our hotline; MRC receives no CMS support for its consumer hotline.
MRC also brings to professional counselors, care givers and consumers across the countryMedicare Interactive
, a web-based counseling tool—developed with major foundation support andwith a seed technology grant from the United States Department of Commerce. MedicareInteractive
assists people with Medicare access benefits, including Part D.
We reach out into low income, minority communities and, in recent months, have concentrated ourservices on enrolling people with Medicare in low income programs – the Part D Extra HelpProgram and Medicare Savings Programs, especially QI-1.
We have launched a Part D appeals program, recruiting a battery of volunteer lawyers andphysicians to assist people with Medicare to obtain medications denied by their Part D plans. Drugplans place the Medicare Rights Center’s toll free phone number on notices informing theirenrollees that the Part D plan is denying coverage of a prescribed medication. Since we receive no
federal or state financial support to assist people with these Part D appeals, we can only make adent in the great need for this assistance. The Committee should know that without competent,independent representation, the Part D appeals and exceptions process is, for most people withMedicare, a sham.
The eight policy recommendations we make are the fruit of lessons learned helping people withMedicare navigate this new drug benefit. We have no political or commercial interest that interfereswith our intent to propose sensible, non-ideological public policies that serve the interest of peoplewith Medicare.
Evaluating Part D
I have been using Aciphex since 2000 for acid reflux. It worked fine but was not onthe Medco formulary. I filed an exception, with a statement from my doctor that Ihad tried all medicines on the formulary and none had helped me as much asAciphex. Medco made it a Tier 3, non-preferred drug. I still have to pay 75 percentof the cost, $284.50 for a three-month supply.
Under my former plan with the State of Virginia, I only paid $32 for a three-monthsupply. That plan stopped covering drugs once Part D started. I appealed to have itmade a preferred drug but it was denied, so I have to pay $1,138 for the medicine Iwas paying $128 for last year. My breast cancer has since returned in my lungs and Ihave to take chemo, which is hard on my digestive system. I am going to try toappeal again.
AliceMechanicsville, VirginiaStory submitted to Part D Monitoring Project
Some members of this Committee and spokesmen for the Administration claim that the figuresreleased last week—over 38 million people with Medicare now have drug coverage, theadministration says—are proof that the Part D program is a success. Enrollment figures, especiallyenrollment figures designed to inflate the impact of Part D, do not tell the story about this newprogram.
According to the Administration, 9.3 million men and women have drug coverage because they areretired federal employees or military veterans or they get coverage from a current or formeremployer with no Medicare subsidy. Their drug coverage has nothing to do with the Part D benefit.
Another 6.8 million people have coverage through a former employer that is now subsidized byMedicare, not through a Part D plan.
Roughly 6.3 million people lost Medicaid coverage on December 31 and were automaticallyenrolled into a Part D plan. Overwhelmingly, the coverage they receive under Part D is worse thanthey had under Medicaid. There are more restrictions and higher out-of-pocket costs. The fact thatNew York and California, both states with Republican governors, have maintained Medicaid drugcoverage as a safety net for these dual eligibles –people with Medicare and Medicaid—into Junespeaks volumes about the deficiencies of Part D.
Another 5.3 million people have drug coverage under a Medicare Advantage plan, usually anHMO. They had drug coverage in 2005. Now with more taxpayer money being committed to privateplans that are already overpaid, according to the non-partisan Medicare Payment Advisory
Commission (MedPAC), they have somewhat better coverage.
About 11.5 million people with Medicare have drug coverage through a stand alone drug plan. Ofthese, over 1 million were autoenrolled either by Medicare because they were low income, or bytheir state pharmaceutical assistance program. That leaves roughly 10 million people whovoluntarily signed up for the Part D benefit. Does that mean Part D is a well designed programthat provides the same health security that people have come to expect from Original Medicare?We think the American people deserve better.
Prescription drug coverage is a crucial component of modern health care coverage. Withmanufacturers threatening to cut off charitable assistance programs and the Food and DrugAdministration ramping up seizures of Canadian medicines, of course people signed up. Part D isjust about the only game in town. Congress made sure of that when it decided to give people abewildering array of plan choices but deny them the one choice they really want --- the option ofreceiving drug coverage directly through Medicare with low prices negotiated by Medicare.
What have people with Medicare experienced under the Part D benefit? Here is a small samplingof the problems our hotline counselors have faced since May 15, when enrollment was closed andmuch of the press attention shifted away.
Formulary restrictions imposed by plans like prior authorization, step therapy and quantitylimits continue to impair access to vital drugs.
Complicated and varied appeals procedures make it nearly impossible for consumers tonavigate the process alone.
Consumer confusion continues to plague critical aspects of the program like eligibility forspecial enrollment periods, calculation of the doughnut hole and coverage of drugs by PartD versus Part B.
People continue to learn of limitations in their coverage that were not disclosed by the plansor the agents that enrolled them.
Problems with coordination of Medicare Part D drug coverage with other benefits like Stateassistance programs, Medicaid or retiree insurance result in higher than appropriate out-of-pocket costs.
Many dual eligibles report that Extra Help co-pays are an excessive financial burden.
Extra Help program is vastly under-enrolled.
Lack of Medicare coverage of benzodiazepines continues to risk stability of people withcertain mental illnesses.
Financial burden of the doughnut hole results in people having their treatment interruptedand losing access to critical medicines.
People who have switched drug plans are not having their accrued drug costs forwarded totheir new plan.
Plans are unaware that individuals who are determined eligible for Extra Help may continueto enroll in drug program.
Individuals who have switched drug plans are charged premiums for both their old and newplan.
Mail order pharmacy programs are sending participants the wrong prescriptions.
People with Extra Help continue to be charged inappropriate co-pays.
Data mismatches between Social Security, the Centers for Medicare & Medicaid Services(CMS), state Medicaid programs and drug plans are still obstructing access to drugcoverage.
The negative publicity that surrounded the implementation of Part D reflected the reality of millionsof people with Medicare struggling to afford the medicines they need under a program that wasnot designed with them in mind. Some, including the Chairman of this Committee, have criticized
those who shared the truth about the hundreds of thousands of impoverished Americans whosehealth and very lives were put at risk by the reckless implementation of Part D earlier this year.
Only an honest appraisal of this program can lead to necessary reforms.
Criticism based in reality is not propaganda. Hiding the truth is. Older Americans and people withdisabilities can tell the difference. Even the many individuals who experienced no problems withtheir Part D plan understand: Health insurance—drug coverage—needs to work every time youneed it, every time you fall ill. Coverage that works some of the time is not insurance, it is RussianRoulette.
To downplay the very real confusion people with Medicare felt when forced to choose from adizzying array of plans, each covering different drugs, charging different copayments and subjectto change at any time, is about spin, not truth. But these Part D boosters – including somemembers of this Committee-- demand that older Americans be sheltered from news accounts thatdescribe Part D accurately. Disguising the truth is not the path to getting public policy right.
Some of the initial problems with Part D implementation have now abated, but our hotline isfielding a new round of frantic calls as more and more people reach the doughnut hole, the gap incoverage that is built into Part D. We have yet to find a drug plan that candidly explained this gapin coverage in their advertising. People with Medicare continue to pay premiums but they mustalso pay full price at the drug store. Estimates suggest that some 7 to 10 million people withMedicare are at risk for reaching the coverage gap. Recent research confirms what many knewintuitively: when people reach a limit on their drug coverage and cannot afford to fill theirprescriptions, they stop taking their medicines. As a result, they get sick, and Medicare pays theprice when they seek emergency care in a hospital. We have no doubt that many people withMedicare will make that fateful choice when they hit the doughnut hole.
That brings us to our first policy recommendation:
FILL THE DONUT HOLE; MAKE MEDICARE NEGOTIATE LOWER PRICES
I had excellent prescription coverage in a supplemental plan that I received from therailroad industry. I paid $125 a month for it but my prescriptions only cost $20 forgenerics and $40 for the brand name drug, and that was for a 4-month supply. Theplan stopped covering prescription drugs when Part D started. Sixty days afterenrolling, I was in the “doughnut hole.” This is going to cost me more than myprevious plan! It is a farce. Congress no longer does any work for the Americanpeople who elected them to office. With Part D (for disaster) they turned the jobover to the insurance and pharmaceutical companies. I am appalled at mygovernment for shoving this down our throats.
LawrenceLady Lake, FloridaStory submitted to Part D monitoring project
We understand that the doughnut hole resulted from the financial constraints imposed onCongress by the White House when it was debating the Medicare Modernization Act (MMA) in2003. But the decision to hand the drug benefit over to private insurers rather than have Medicaresecure lower prices precluded savings that could have been used to fill the coverage gap. Studiesshow that if Medicare secured the same prices that the Veterans Administration or otherindustrialized countries pay, there would be enough money to fill the doughnut hole. Weappreciate that there is much debate, some of it informed, about this assertion. Circumstantialproof of Medicare’s effectiveness as a negotiator is found in the pharmaceutical industry’s virulentopposition to allowing Medicare to negotiate drug prices. If private plans were so successful at
driving down drug prices, don’t you think your former colleague, now lobbying for PhRMA, wouldbe here fighting to require that Medicare, and not the plans, negotiate drug prices? Is thisCongress prepared to stand up to the pharmaceutical industry for older Americans and peoplewith disabilities? Existing evidence is not encouraging.
We realize that these are far reaching demands and that many in Congress are invested in theprivatized structure they created in Part D. However, there are other steps that Congress can andshould take to improve and extend drug coverage to people with Medicare.
ELIMINATE THE ASSET TEST FOR THE LOW INCOME SUBSIDY
Violet, a retired resident of Montgomery County, New York, receives $1006.50 eachmonth from Social Security. Although her monthly income falls below the ExtraHelp income limit of $1225 per month, she is not eligible because she has $13,000 inassets, $1,500 over the income limit. Because she lives in New York, she can qualifyfor a Medicare Savings Program (MSP), which will pay her Part B premium andautomatically enroll her in the Extra Help program. This is possible because NewYork has eliminated the asset test for the QI-1 program, the MSP program for peoplewith Medicare earning less than 135 percent of the poverty line. Only five otherstates have eliminated the asset test for any of their MSP programs.
Since the beginning of the debate of the MMA, there has been widespread, bipartisan agreementthat the number one priority of a Medicare drug benefit is to assist the poorest Americans insecuring the medication their doctors prescribe. The low income subsidy, popularly called theExtra Help Program, offers the promise of a comprehensive and affordable drug benefit – so longas the patient selects a drug plan that works for her.
One of MRC’s key priorities over the past six months has been to enroll as many people in thatbenefit as humanly possible. With funding from the Starr Foundation and Robin Hood Foundation,among others, we have enlisted hundreds of volunteers to reach out to likely candidates for ExtraHelp, explain the program to them and whenever possible enroll people online. We are probablyas sophisticated as anyone in conducting this work. We advertise a toll free phone numberthrough AARP, chain drug stores, senior centers and elsewhere. We have public serviceannouncements and look to work cooperatively with drug plans, which gain enhanced paymentswhen we sign up their enrollees in Extra Help. We work with pharmaceutical companies thatsupply us with contact information for people with low incomes who have been disqualified fromtheir patient assistance programs because of Part D: they are good prospects for Extra Helpeligibility. Still, the results are dismal: it routinely takes 33 calls by MRC volunteers and staff toidentify a likely candidate for the Extra Help Program.
The administration now says that there are 3.2 million people who qualify for the Extra Helpprogram but are not enrolled and have failed to sign up for Part D. That number is surely low. Butwithout quibbling over numbers, we should all agree that leaving 3.2 million impoverished olderAmericans and people with disabilities without drug coverage, in the context of a trillion dollarbenefit program, is not a success story. Congress should take immediate steps to remedy thissituation. Pinning our hopes only on renewed outreach efforts will not find and enroll thishard-to-reach population.
The first step is to eliminate the asset test for the Part D program. The asset test disqualifies overhalf of the low income people with Medicare who apply for Extra Help. It penalizes working classAmericans who have diligently saved for their retirement.
The asset test also discourages eligible individuals from applying. It makes the applicationneedlessly complicated, for instance, by requiring individuals to calculate the face value of theirlife insurance policies. The asset test also creates a barrier to automatically enrolling people basedon income data already in the possession of the federal government. When Congress decided tomeans test the Part B premium for higher income people with Medicare, it found a way to do itautomatically, based on IRS data. Similar efforts should be made to automatically enrolllow-income individuals in the Extra Help program.
REQUIRE MEANINGFUL PART D PLAN COMPARISONS
Reasonable public policy would not require people with Medicare to shoot in the dark to pick adrug plan that would work for them. We have worked hard to help people with Medicare select adrug plan that has a good chance of working for them. Secretary Leavitt, according to publishedreports, made a similar if less successful effort to assist his parents in selecting a drug plan. LasVegas-style gambling on one’s health care is not what we should be purchasing for our parents,our grandparents and ourselves. But that is what Part D provides.
Many callers to MRC’s hotlines are among the more sophisticated of consumers. They did whatthe President and others told them to do. They found help with the internet, they found a plan thatsaid it covered the drugs they now are taking, they found a plan with premiums and deductiblesthat seemed affordable, and they signed up.
Now they call us in a panic. They never understood that a “covered drug” could come with a $100per prescription co-payment. They never thought that a “covered drug” would come with trapdoors– requirements that they try other medications first, or that their doctor would have to agree tobecome a witness in a legal appeal so they could get the “covered drug.” Almost no one nowhitting the gap in coverage, the infamous doughnut hole, was told about this by the plans. Howmany brokers, people earning commissions for each person they enroll, do you think told theircustomers about the doughnut hole?
If a majority of the members of Congress continues to support this marketplace experiment, twosteps could help: one, Congress should authorize a drug benefit integrated into Medicare to serveas a reliable safe harbor, a genuine choice, for people dissatisfied with the private plans; and two,Congress should force a more finite number of plans into meaningful comparisons that will allow,however imperfectly, some consumers to make a less risky selection.
END MARKETING ABUSES
I am a 47-year old woman who has been disabled for 9 years. I had originally beenenrolled in HIRSP, Wisconsin’s state insurance plan for high risk members, in whichI paid $333 a month to cover my health care costs. This plan covered all of mymedications, but the payments were starting to put some strain on my limitedresources, making me more receptive when a sales representative from a privateinsurance Part D plan visited my home.
That’s when the trouble started. Though I was concerned about whether or not Icould switch back to HIRSP, the salesman convinced me that I would have noproblem switching back if I didn’t like the plan. I asked him if he was sure, and thesalesman told me that a client had recently gone back to HIRSP insurance after fourmonths because he wasn’t happy with the plan. I had no reason not to believe him –after all, he seemed very knowledgeable about HIRSP and its policies.
After about two months with this new plan, my health was worsening so I decided toreturn to HIRSP. However, I was told that because I voluntarily left the insuranceplan, I had to wait a year before I could sign up again.
My new plan is costing me much more than I had ever paid with my old insurance,even though it doesn’t cover all of my prescriptions, and I have had to skiptreatments. A HIRSP representative told me that other people had also been told bythis insurance plan that they could switch back when they wanted. I feel that I wasduped by this plan, and I worry about others who are also in my situation. Now all Ican do is endure the wait until next year.
SueWest Bend, WisconsinStory Submitted to Part D Monitoring Project
MRC’s experience with frantic callers to our hotline is leading us to the unhappy conclusion thatnearly all marketing of Part D plans is misleading, nearly all of it exploitative of the neediest andfrailest older Americans. Worst off are people who were contacted by telemarketers, a practicesanctioned by CMS. Caller after caller tell us that they did not know much about the plan they hadenrolled in, and that they had been told things that were just not true. Other callers tell us thatthey did not know that they had signed up for an HMO, not a drug plan, until their doctorpresented them with a bill and told them he is out of the HMO’s “network.” Increasingly, as peoplefall into the gap in coverage, the infamous “doughnut hole,” they are shocked. Why?
The design of this privatized drug program creates a single commercial incentive for the drugplans, the brokers they employ, and the marketing firms they retain. The incentive: market share.
Even putting aside purposeful fraud by the unscrupulous, deception is an inevitable by-product ofthis market created by the MMA and CMS.
Have you reviewed marketing material from the drug plans? Have you heard sales pitches at freebreakfast meetings? At senior centers? A plan with a low deductible or a low premium willhighlight that feature. People will be sold low deductible plans without understanding the otherside: restricted formulary, rigid medication utilization tools, and excessive costs per prescription.
How many members of Congress have seen plan marketing materials – TV ads, brochures radiospots – talk about the gap in coverage? Even CMS is part of the problem. Late last year CMSspent untold public dollars running an insert about Part D in Parade Magazine
. CMS, supposedlyexplaining the standard drug benefit, neglected to even mention the doughnut hole. Shareholdersare protected by the Securities Exchange Commission and securities laws. Aren’t older Americansentitled to similar protections from the predatory practices of the insurance industry? Deceptioncomes in many forms: omitting material information from drug plan advertising is one that isepidemic in Part D.
Telemarketing of drug plans must be banned, and all marketing materials must be limited toaccurate and comprehensive comparisons of standardized plans.
IMPROVE ACCESS TO MENTAL HEALTH DRUGS
Karen has Medicare and Medicaid and was autoenrolled in the AARP plan offeredby United Healthcare. In January, she attempted to fill prescriptions for threeantidepressants, Mirtazapine, Wellbutrin and Cymbalta, but United Healthcarewould not pay for the prescribed doses. United Healthcare set a quantity limit foreach drug at 30 pills per month.
Karen has Severe Refractory Depression and has been prescribed numerouscombinations of various drugs over the past eight years. Lower doses of all threedrugs had been tried and failed to provide relief. According to both her treatingphysician and a consulting psychiatrist, this is the only combination that gives herany relief.
Despite this evidence of medical necessity, United Healthcare twice denied coverageof these medicines at the prescribed dosages. Maximus, the independent reviewentity contracted by CMS, also rejected Karen’s appeal. The case is now before anadministrative law judge.
Clients continue to flock to MRC seeking help with barriers drug plans are putting in the way ofaccess to antidepressants and antipsychotics, drugs commonly needed by people with mentalillnesses. As you know, CMS required plans to cover “all or substantially all” of these medicines,along with drugs in four other critical therapeutic classes. But that requirement is beingundermined by other restrictions imposed by plans -- prior authorization, step therapy and quantitylimits. Quantity limits, in particular, are billed as “safety edits,” but drug plans (seeking, of course,to maximize profits) generally impose them only on the most expensive drugs. Cost, not safety, ismotivating the plans.
One important, and relatively inexpensive, class of drugs – benzodiazepines – is excluded by lawfrom Part D coverage. This exclusion threatens the stability of the drug regimens of many peoplewith mental illness. Most state Medicaid programs continue to provide coverage but many peoplewith low incomes do not qualify for Medicaid, and states are under financial pressure to cut backcoverage. In Florida, people who qualify for Medicaid through spend down are finding it difficult tomaintain access to these medicines.
Congress should end the exclusion of benzodiazepines from the Part D benefit. It should ensureadequate coverage of mental health drugs and should enjoin plans from doing an end run aroundformulary requirements with utilization management dodges.
STANDARDIZE, STREAMLINE PART D EXCEPTIONS AND APPEALS
Parts A and B of Medicare have worked well because they are based on the concept thatindividuals will have access to care deemed medically necessary by their treating physician. Intheory, drugs under Part D are supposed to follow a comparable concept: while Part D consists ofa patchwork of plans with various options and limitations on prescriptions, the MMA also includesexceptions and appeals provisions intended to allow individuals to access medically necessarydrugs.
We now know from our first hand experience that the current system fails to deliver on thisbedrock concept – access to medications that are medically necessary. Over the last severalmonths MRC has helped hundreds of men and women take on the Part D appeals system. Mostof our appellate clients had been denied access to medically necessary medications, and almostall were stymied by the Part D appeals process. Here are ways to improve this flawed, consumerhostile system:
standardize the appeals process and forms;
provide resources for independent consumer organizations to provide representation topeople denied medically necessary medicine.
The Part D appeals process is impossible for the average consumer to navigate. Following nearuniversal criticism, the recent move to standardize the coverage determination request form is awelcome, but very small start. Use of these forms by plans is voluntary, and they are only the firststep in a multi-step appeals process. Steps must be taken to standardize the rest of the appealsprocess. There should be one form and one set of rules for obtaining an exception. That form andthose rules should be posted on the CMS website and mailed to all people with Medicare.
Obtaining life-saving medications should not be akin to navigating a mine-field.
I have been denied coverage for Byetta, a medication I have been on for mydiabetes for nearly a year. When I was first denied, I was told by my Part D plan,Wellcare, that my doctor only needed to fill out a form and the Byetta would beadded to the allowed list, which it has not. I have been denied coverage for thismedication. I have also had to get prior authorization for my asthma meds, Singulairand Spriva. It took over a month to get the authorization, during which time Ibecame ill. I am constantly charged copays on syringes, insulin and albuterol, whichI did not have to pay before Part D. I get charged copays for generic meds, whichare supposed to have a $0 copay. I have called the insurance company and havebeen told that my many prescriptions cost too much, and I will have to pay copayson everything. I have tried to work with the pharmacy to get all of my prescriptions.
They now look at me like I am a problem when I go to pick up a prescription.
AndreaEast Wareham, MassachusettsSubmitted to Part D Monitoring Project
A standardized appeals process must also be a streamlined one. Individuals should receive aformal denial before they leave their pharmacy, complete with straightforward instructions on howto appeal that denial. After an initial appeal to a Part D plan, individuals would then appeal directlyto the Independent Review Entity.
This would cut out an unnecessary and generally futile step. Currently, after being denied a claimat the pharmacy, people with Medicare must ask the plan twice to cover their drug before receivingan independent review. Drugs subject to prior authorization require three requests for coverage atthe plan level before an independent review is allowed. Each of these preliminary steps causesdelays in violation of mandatory timelines and at considerable risk to the well being of the patient.
Further, for the current process to be meaningful, people with Medicare require assistance inprosecuting appeals. The current system assumes a helpful and willing physician. Do members ofthis Committee know many doctors who are routinely willing to take on arduous, uncompensatedpaperwork for the sake of their patients? And who is to help patients pursue appeals?
As noted, MRC is listed on plan denial forms as a go-to patient advocate for people deniedcoverage of medicines prescribed by their doctors.
How much does CMS contribute to this representation?
If Congress wants people with Medicare to have access to medically necessary drugs, it muststandardize and streamline the Part D appeals process, and provide assistance to individuals withbona fide appeals of a plan’s denial of medically necessary medications.
DELAY ENROLLMENT PENALTY AND END LOCK-IN
Now that the May 15th enrollment deadline has passed, many people find themselves locked in totheir prescription drug plan or locked out of drug coverage all together until the next openenrollment period. Starting July 1, people will be locked in to their Medicare Advantage plan.
The prospect of a late enrollment penalty, which accrues during the months people with Medicareare locked out of drug coverage after May 15 and will rise each year as the average drug planpremium rises, created needless anxiety among people with Medicare already frustrated by aconfusing choice of plans. As a result, many people enrolled in plans without knowing what thecoverage restrictions are, or that they will only be able to use doctors and hospitals that arein-network. Many have been deceived by plan marketing agents on these very issues.
MRC has spent the last 15 years helping people disenroll from their Medicare HMO so that theycould continue to receive care from their treating physician. Others need to disenroll when theydiscover that the plan provides no help with cost sharing for chemotherapy or other seriousillnesses. Among drug plan enrollees, plans’ failure to cover their medicines is the primary reasonpeople seek to disenroll. The administration should lift lock-in under its broad authority to createspecial enrollment periods. If it fails to act, Congress should step in.
The prospect of a late enrollment penalty creates needless anxiety among people with Medicarealready frustrated by a confusing choice of plans. The late enrollment penalty accrues during themonths people with Medicare are locked out of drug coverage after May 15 and will rise each yearas the average drug plan premium rises. With all the problems and confusion associated with theroll-out of the Part D benefit, it is inevitable that some people with Medicare will miss theenrollment deadline. Congress should step in and waive the late penalty for 2006.
ENACT A MEDICARE DRUG BENEFIT
These reforms would be helpful, because we believe in the principle that anything that helps asingle person is a worthy reform. But, even with these reforms the drug benefit will continue towaste billions of dollars that could better be used to deliver a reliable and comprehensive drugbenefit to people with Medicare through the Medicare program.
Americans need affordable prescription drug coverage that meets our changing health careneeds, a program that cover the drugs we need today – and the drugs we will need tomorrow.
Medicare provides a cost effective and largely affordable safety net, reliably allowing older anddisabled Americans the peace of mind and the security of knowing that medically necessary andreasonable health care services will be covered. There is a human cost to abandoning thatMedicare design for the coverage of prescription drugs.
To provide a benefit as good as we can afford with finite dollars, we think the lessons of Part D –objectively evaluated – teach that Congress should enact:
A drug benefit administered directly by Medicare, without the waste and restrictions thatcome with private health insurers as commercial, profit seeking middleman;
Negotiated drug prices that keep costs down; and
One comprehensible, reliable and secure drug benefit that adapts to the needs of theAmerican people now and in the future.
Health security, not a health care lottery, is what people with Medicare require. People may ingood faith still believe, even after the evidence of 2006, that the new cottage industry of for-profitmiddlemen hawking incomprehensible drug benefit packages is the way to go. We do not thinkso. But we are content to allow those plans to continue, so long as these middlemen face a realmarket. Let the for-profit insurers compete with a Medicare drug benefit, one that fights for lowerprices, and keeps administrative costs low and profiteering non-existent.
Honest supporters of a market approach cannot fear competition, not even from Medicare. There isnothing to fear but a better deal for people with Medicare and a fairer deal for the Americantaxpayer.
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