By Rebecca A. Clay
To understand the key changes ahead, the following elements
Shift to Medicare Prescription Drug Coverage.
Starting in January 2006, every person with Medicare
will be eligible for coverage to help pay for prescription
drugs. For many people, this means they will have
prescription drug coverage for the first time. For
people with both Medicare and Medicaid, it means
that Medicarenot Medicaidwill pay for
their prescription drugs starting January 1. However,
Medicaid will continue to pay other mental health
and substance abuse treatment costs for dually eligible
New prescription drug plans. Under
the new program, dozens of prescription drug plans,
insurance companies, and other private organizations
approved by Medicare will negotiate with pharmaceutical
manufacturers to offer Medicare prescription drug
plans at the most affordable prices. Every beneficiary
will have a choice of at least two plans in his or
her community. Information about the prescription
drug plans will be available in the Medicare
& You 2006 handbook mailed to all people
with Medicare this October.
Coverage. The prescription drug
plans will cover both generic and brand-name medications.
Their formularieslists of medications availablemust
least two medications within each class of drug.
For the six drug classes CMS calls "of special
interest," the formularies will include virtually
Three of these drug categories affect consumers with
mental illness: antidepressants, used to treat depression;
antipsychotics, used to treat schizophrenia and psychosis;
and anticonvulsants, used to treat bipolar disorders.
"By far and away, most people will be able to stay
on their current medicines," said Anita Everett,
M.D., Senior Medical Advisor at SAMHSA.
Costs. Costs are another area of
difference between dually eligible people and other
beneficiaries. While most beneficiaries will have
to pay a premium, dually eligible consumers won't.
Beneficiaries whose income and resources are limited,
but not low enough to qualify for Medicaid, can apply
for extra help, which dually eligible beneficiaries
will receive automatically. Dually eligible people
will, however, have to make copayments on individual
prescriptions. For persons who have both Medicare
and Medicaid, the copayments per prescription will
be no more than $1 for generic and $3 for brand name.
Those with limited income will pay no more than $2
for generic and $5 for brand-name medications.
Choice. Dually eligible people
don't have to stick with the plan CMS assigns them.
Unlike most beneficiaries who can change drug plans
only once a year, people with both Medicare and Medicaid
will be allowed to change plans anytime. "If
dually eligible consumers don't like the plan they're
assigned to or feel it isn't the best fit in terms
of their needs or preferences, they can switch,"
said Dr. Everett.
Substance abuse. Medication is
sometimes used in specific situations in substance
abuse treatment, and prescription drug plans may
cover such medication. Plans must cover at least
two medications in the alcohol aversion category,
which includes naltrexone (Revia®, Trexan®),
acamprosate (Campral®), and disulfuram (Antabuse®).
In addition, plans are required to cover smoking
Plans also may cover buprenorphine, a medication used
for treating opioid addiction.
A seamless transition. Most beneficiaries
will have to research the prescription drug plans
in their area and select the one that meets their
needs. To ensure continuity of care, CMS will enroll
dually eligible people automatically in a Medicare
prescription drug plan if they don't join one on
their own by December 31, 2005. "Many of the
dually eligible consumers have serious mental illnesses
or cognitive impairments," explained Dr. Everett.
"There was a concern that they would fall through
the cracks if they weren't automatically enrolled."
This automatic enrollment helps to ensure that individuals
with both Medicare and Medicaid don't miss a day
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Some observers are worried about the impact of the new
Medicare prescription drug coverage.
"We're concerned about the implementation of the
Medicare Modernization Act and its impact on providers
and the consumers they serve," said Linda Rosenberg,
M.S.W., President and Chief Executive Officer of the
National Council for Community Behavioral Healthcare.
"We have been working closely with CMS and SAMHSA
and have appreciated their leadership in efforts to make
this a smooth transition for everyone."
Major concerns include the following:
Cost-containment measures. "It's
important to keep in mind that Medicareincluding
this new prescription drug coverageis an insurance
plan. As such, Medicare uses the same cost-containment
and quality assurance measures used by private insurance
companies," said Dr. Everett.
important to keep in mind that Medicare-including
this new prescription drug coverage-is an insurance
plan. As such, Medicare uses the same cost-
containment and quality assurance measures used
by private insurance companies.
Some observers are concerned that those measures could
make it harder for beneficiaries to obtain specific medications.
"We're concerned about individuals who are clinically
stabilized who might have to switch medications,"
said Sam Muszynski, J.D., Director of the Office of Healthcare
Systems and Financing at the American Psychiatric Association.
CMS, working closely with SAMHSA as well as stakeholder
groups, has developed a set of checks and balances to
protect patients with mental illnesses. For example,
Medicare will use "risk adjustment"whereby
prescription drug plans are compensated differentially
for certain high-risk usersto reduce incentives
for plans to deny specific medications or benefits to
certain beneficiaries as a way to reduce costs. Comparative
analyses will be conducted between plans to assure that
drug use patterns do not represent discrimination against
high-cost categories of illnesses.
Among other protections, CMS will require every Medicare
prescription drug plan to establish a transition procedure
for accommodating individual medical needs. This procedure
must ensure that consumers have access to medications
that work for them, even if those medications are not
CMS also created an appeals process. Prescription drug
plans are required to respond to an enrollee's request
for a decision within 24 hours under an expedited coverage
determination and within 72 hours for a standard coverage
determination. CMS established a Medicare Beneficiary
Ombudsman Office to provide a troubleshooting mechanism
"Overall, NAMI is pleased with the collaboration
and cooperation of SAMHSA and CMS to make this transition
as smooth as possible," said Andrew Sperling, Director
of Legislative Advocacy at the National Association for
the Mentally Ill (NAMI).
Benzodiazapines. Currently, Medicare
Part A covers benzodiazepines for detox purposes
in an inpatient setting. However, by law the new
Medicare prescription drug coverage (Medicare Part
D) must exclude coverage of benzodiazepines, often
used for treating anxiety and panic disorders.
"That was in the actual legislation, so there's
nothing CMS can do about that," explained Dr. Everett.
Legislation was introduced in Congress in July to remove
the exclusion of benzodiazepines from Medicare prescription
drug coverage. As SAMHSA News was going to press,
no conclusive action had been taken yet.
Possible confusion. "Navigating
benefit programs is not an easy thing, especially
with a brand-new program," said Andrew D. Hyman,
J.D., Director of Government Relations and Legislative
Counsel at the National Association of State Mental
Health Directors. In addition, he noted that many
individuals with mental illness are "poor and
ill," increasing their vulnerability.
Recognizing the need for clear and accessible explanations,
SAMHSA has been working with a number of advocacy groups,
such as the National Association of State Mental Health
Program Directors, to provide specific information to
people with mental illness and substance use disorders.
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"The Federal Government will work hard to ensure
that Medicare beneficiaries understand their options,"
said President Bush in a recent address on Medicare.
By now, people with both Medicare and Medicaid should
have received a letter from CMS explaining that they
automatically qualify for extra help. And in the fall,
CMS will also send Medicare & You 2006 to
all Medicare beneficiaries. The handbook explains Medicare
prescription drug coverage and contains a list of plans
available in the area.
CMS will also partner with more than 90 patient, consumer,
advocacy, and support organizationsthe Access to
Benefits Coalitionto provide personalized assistance.
SAMHSA is working with advocacy groups, provider groups,
and other stakeholders to educate their members about
the changes ahead. SAMHSA is also working with CMS to
develop fact sheets and other materials.
SAMHSA News will report on continuing developments
as they unfold.
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The State Perspective
Consumers aren't the only ones the Medicare Modernization
Act will affect. "There's a lot of anxiety
in the states about how this will affect them,"
said Charles Ingoglia, M.S.W., Special Expert in
the Office of Program Analysis and Coordination
in SAMHSA's Center for Mental Health Services.
Costs are a major concern. Currently, states match
the Federal Government's contribution toward Medicaid
beneficiaries' prescription drug costs. Shifting
those costs from Medicaid to Medicare doesn't eliminate
those costs, however. A provision called the "clawback"
requires states to use the savings gained by no
longer offering prescription drugs through Medicaid
to reimburse the Federal Government in part for
the new benefit.
Simply initiating the new program will also take
money, said Andrew D. Hyman, J.D., Director of
Government Relations and Legislative Counsel at
the National Association of State Mental Health
Directors. And at least some of the burden of helping
consumers choose the Medicare prescription drug
plan that's best for them will fall on state mental
health agencies and their providers. "State
mental health agencies have a huge responsibility
when it comes to the issue of education and outreach,"
« See Part 1: Medicare Modernization Brings Big Changes
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