WHAT LONG-TERM CARE RESIDENTS AND THEIR CAREGIVERS NEED TO KNOW ABOUT MEDICARE’S NEW DRUG PRESCRIPTION COVERAGE (AND HOW YOU CAN

This month, Medicare and dual Medicare-Medicaid beneficiaries will start signing up for Medicare’s new prescription drug insurance plans. Enrollment begins November 15, and for those who sign up by December 31, coverage begins January 1, 2006. The date marks a major transition for older adults and for long-term care facilities.

Everyone with Medicare in long-term care will qualify for the new Medicare benefit (which will be offered through regional Medicare prescription drug plans, and as part of Medicare managed care, now known as Medicare Advantage). The Centers for Medicare & Medicaid Services (CMS) is requiring all plans to cover beneficiaries in all nursing homes in their regions. It’s also requiring the plans to arrange for medications to be packaged and made available to nursing homes through long-term care pharmacy providers. (According to CMS, these will most likely include both current pharmacy providers to nursing homes and new organizations that meet the agency’s long-term care pharmacy guidelines.)

There’s a good chance that some of the older adults in your care, or their loved ones, have already started asking you questions about the new benefit. In a recent study, the Kaiser Foundation found that the number one source of information on Medicare prescription drug coverage for seniors is their physician. The American Geriatrics Society has pulled together, on one user-friendly page, Web-based resources on the drug plan that have been created by a number of leading organizations in this area. Among other features, the AGS site https://www.americangeriatrics.org/news/medicarePart_D.shtml includes links to easy-to-understand information for beneficiaries.

Following are a few key points you might consider sharing with those in your care:

Why, How and When to Enroll
It’s particularly important that Medicare beneficiaries understand that they must enroll in a Medicare drug plan to receive benefits, and that enrolling by May 15, 2006, could save them money on monthly premiums. Those who wait longer won’t be able to enroll until the next “open enrollment period,” which starts November 15, 2006, and runs through December 31 of that year. What’s more, if they wait, they’ll have to pay higher premiums unless the prescription drug coverage they had after May 15, 2006, was as good as Medicare coverage.

Dual Medicare-Medicaid beneficiaries—about two-thirds of those in long-term care—should know that their Medicaid drug coverage will end December 31, 2005, and that they’ll then receive prescription coverage under one of the new Medicare health plans. They should also realize that Medicare will choose a plan for them if they don’t choose one themselves by December 31. (If that happens, however, they’ll be able to switch to another plan later.)

The Cost of Coverage
Dual Medicare-Medicaid beneficiaries in nursing homes won’t pay anything for the new prescription drug coverage. Dual beneficiaries in assisted living or adult living facilities or residential homes will pay a small copayment for each prescription drug, although some states will cover these expenses for their residents. For Medicare-only beneficiaries, the costs are a bit more complicated. Monthly premiums differ from plan to plan, but the average premium is about $32; the annual deductible, $250; and initial copay, about 25% of the cost of the first $2250 in medications. Then there’s a gap in coverage: beneficiaries will have to pay the entire cost of drugs until they’ve paid another $2850 out of pocket. After that, Medicare will pay about 95% of the cost of drugs the rest of the calendar year. The exact amount can be calculated using the Medicare Prescription Drug Plan Cost Estimator (https://www.medicare.gov/medicarereform/minitool.asp).

Differences Among Plans
Beneficiaries will have a choice of several plans in their region. In addition to premiums, formularies will vary from plan to plan. While plans will offer different formularies, CMS has required all plans to cover a range of drugs in the most commonly prescribed classes. In addition, beneficiaries will be able to make use of an exceptions and appeals process for access to nonformulary drugs. And while appeals are being adjudicated, CMS will require plans to provide emergency supplies of nonformulary drugs to beneficiaries in long-term care facilities.

Financial Help with Costs
People who have limited incomes and resources but don’t qualify for full Medicaid benefits may qualify for extra help paying premiums, deductibles, and copayments. This extra help is through a low-income subsidy that is available through the Social Security Administration at https:// www.socialsecurity.gov.

Because there are many variables affecting coverage, CMS is urging healthcare professionals to refer beneficiaries to 800-MEDICARE or https://www.medicare.gov for specifics and individualized assistance. To enable you to stay on top of developments regarding the new drug benefit, the agency also recommends keeping an eye out for correspondence from CMS. You can register to receive agency listserv emails regarding the benefit (and other Medicare information) at https://www.cms.hhs.gov/ medlearn/matters.