Fwd: Issue 26, December 23, 2008

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Welcome to MEDICARE WATCH, a biweekly electronic newsletter of the

Medicare Rights Center

Vol. 11 , No. 26: Decemeber 23, 2008

Contents:

1. FAST FACT

2. CBO PEGS COST OF ENDING TWO-YEAR WAIT FOR MEDICARE

3. DRUG PLANS RAISE COST, RESTRICT ACCESS FOR CANCER MEDS

4. REPORT OUTLINES ISSUES FOR DESIGNING MEDICAL HOMES

5. CASE FLASH: CONTINUING EXTRA HELP ELIGIBILITY FROM ONE YEAR TO THE

NEXT

1. FAST FACT

Between January and April of 2007, people with Medicare in Private

Fee-For-Service plans (PFFS) disenrolled at an average rate of 21

percent.

(“

Characteristics, Financial Risks, and Disenrollment Rates of

Beneficiaries in Private Fee-for-Service Plansâ€, Government

Accountability Office, December 2008).

2. CBO PEGS COST OF ENDING TWO-YEAR WAIT FOR MEDICARE

Eliminating the 24-month Medicare waiting period for individuals who

qualify for Social Security Disability Insurance (SSDI) will cost the

federal government $113 billion over ten years, while reducing the wait

for Medicare coverage to 12 months would cost $65 billion, according to a

new analysis of health policy options by the Congressional Budget Office

(CBO).

Another alternative would eliminate the waiting period for Medicare

coverage for individuals who have no access to private insurance. Studies

have found that about a fifth to a third of people in the two-year

waiting period are uninsured, while others have private coverage through

COBRA, or through a spouse’s employer or retiree plan. Eliminating the

waiting period for those without private insurance would increase federal

spending by $56 billion over 10 years. The final alternative would

eliminate the 24-month waiting period only for people who have no access

to private insurance or to Medicaid coverage. This option would add $28

billion to federal spending. These last two options would create new

administrative costs to verify that those individuals do indeed lack

insurance.

In separate cost projections included in the report, CBO estimated that

taxpayers would save $110 billion over ten years by requiring

manufacturers of brand-name drugs to pay the federal government the same

rebate paid to state Medicaid programs for drugs covered under the

Medicare Part D drug benefit. CBO also estimated the cost of eliminating

the Part D doughnut hole, the gap built into drug coverage, at $134

billion over ten years.

3. DRUG PLANS RAISE COST, RESTRICT ACCESS FOR CANCER MEDS

It will be more difficult for cancer patients enrolled in Medicare Part D

to obtain oral cancer drugs in 2009, because over the past three years,

prescription drug plans have increased out-of pocket costs and imposed

more restrictions on these medications, according to a new report

released by Avalere Health and the American Cancer Society Cancer Action

Network (ACS CAN).

Drug plans categorize drugs into formulary tiers that determine the

cost-sharing for enrollees. For 2009, most drug plans have placed

commonly prescribed brand-name oral cancer drugs in specialty tiers that

require higher cost-sharing, ranging from 26 percent to 35 percent of the

drug's price. People with Medicare cannot appeal for lower cost sharing

if a drug is placed in the specialty tier.

Since 2006, drug plans have been slowly shifting oral cancer drugs into

specialty tiers. For example, in 2006, 39 percent of drug plans put

Gleevec, a brand-name medication used for the treatment of leukemia and

other forms of cancer, in specialty tiers, compared to 84 percent of

plans in 2009.

In addition, drug plans are requiring more prior authorizations for these

oral cancer drugs. In 2006, 35 percent to 43 percent of plans required

prior authorizations for these brand-name drugs, whereas in 2009, 62

percent to 70 percent of plans will require prior authorizations,

depending on the medication.

Changes in formulary tiers and prior authorization policies may interrupt

or reduce available treatments for people with Medicare if they are no

longer able to afford a medication or access the medication due to new

restrictions.

4. REPORT OUTLINES ISSUES FOR DESIGNING MEDICAL HOMES

The “medical home†model has gained significant support as a means

for reforming the health care delivery system, but critical operational

issues have the potential to make or break the rollout of a medical home

program, according to a new report by the Center for Studying Health

System Change and Mathematica Policy Research.

A medical home is a physician practice committed to coordinating care

based on patients' needs and priorities, and focused on integrating care

across settings and practitioners.

The first critical issue addresses the importance of building a medical

home on a solid primary care foundation that emphasizes accessible,

continuous, coordinated and comprehensive care. Because of time and

inadequate financial support for coordinating care, not all primary care

practices are set up to function as primary care medical homes. Since

primary care doctors play a central role in coordinating care and

building a relationship of trust with their patients, they play a central

role in the medical home model. Without adequate financial support,

primary care doctors will have difficulty fulfilling all the functions of

a medical home.

Equally important is the process of matching a patient to a proper

medical home. The report advocates using assignment procedures that

provide patients with adequate choice and create awareness on the part of

the patient. Without a doctor-patient conversation about how the medical

home model works, many patients will continue to use specialist care

outside the medical home model, making it more difficult to coordinate

care.

For the medical home model to work, funds are needed to pay doctors for

information systems and for care coordination activities, perhaps by

using per-patient payments, since payment systems used by Medicare and

private insurers generally do not compensate doctors for these

activities.

5. CASE FLASH: CONTINUING EXTRA HELP ELIGIBILITY FROM ONE YEAR TO THE

NEXT

Mr. L has Original Medicare Parts A and B and a stand-alone Part D

prescription drug plan. In November of last year, he applied for Extra

Help, the federal program that helps with most of the costs of Medicare

Part D coverage. Mr. L qualified for partial Extra Help, which reduced

his Part D premium, deductible and copayments for all of 2008. However,

Mr. L recently received a letter in the mail letting him know that his

Extra Help would end on December 31st.

Mr. L called the Medicare Rights Center hotline and spoke with a

counselor about his Extra Help status. The counselor asked Mr. L whether

his income or assets had changed in the past year. Mr. L said his income

had not changed significantly. The counselor assessed that Mr. L should

still be eligible for Extra Help in 2009. The hotline counselor then

asked Mr. L whether he had received a form from Social Security called

“Review of Your Eligibility for Extra Help.†The counselor explained

that when you apply for Extra Help, Social Security will sometimes send

out a form in August or September to assess whether you continue to

qualify for Extra Help. Not everyone gets the form, but those who

do receive it must fill it out. If you receive the form and do not

return it, your Extra Help will not be recertified, and your assistance

will stop at the end of the year.

Mr. L looked through his old mail and found that he had received a

recertification letter, but, since his income and assets had not changed,

he had not realized that he was supposed to return the enclosed form to

Social Security. The counselor told Mr. L that even though his Extra Help

was set to end, he could reapply for assistance for the following year by

going in person to his local Social Security office, or by applying

online at

www.ssa.gov. The counselor advised Mr. L to reapply as soon as

possible to ensure that his Extra Help coverage continuesin January 2009.

Mr. L took the counselor’s advice and went to his local Social Security

office that day to reapply for Extra Help for the following year. Four

weeks later, he was notified that he would again have partial Extra Help

coverage for the year in 2009.

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Medicare Watch is the Medicare Rights Center’s

fortnightly newsletter, established to strengthen communication with

national and community-based organizations and professional agencies

about current Medicare policy and consumer issues. Each edition contains

news of recent policy developments affecting Medicare and health care

generally and a case story from our hotline that illustrates steps

professionals can take to get older adults and people with disabilities

the health care they need.

The Medicare Rights Center is a national, not-for-profit consumer service

organization that works to ensure access to affordable health care for

older adults and people with disabilities through counseling and

advocacy, educational programs and public policy initiatives.

© 2008 by Medicare Rights Center. All rights reserved.

For reprint rights, please contact

Sheena Bhuva.

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