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MEDICARE REFORM


MEDICARE REFORM & PRESCRIPTION DRUG COVERAGE

On November 25th, by a vote of 54-44, the Senate approved the broadest changes in the Medicare program’s 38-year history by adding a prescription drug benefit.  The Senate vote followed a close 220-215 vote in the House on November 22nd.   The President is expected to sign this landmark legislation soon.  Although the Society has some reservations about the provisions in the Medicare bill– such as private sector administration of the drug benefit, sufficient protections for people with low incomes and Health Savings Accounts – on balance, this legislation appears to be the best opportunity to add a Medicare drug benefit.  The Society will continue to work diligently to resolve our concerns during the implementation phase and, if necessary, would support legislation to improve existing benefits.

How Rx Coverage Would Work.   Given the cost limit of $400 billion over ten years and widely divergent philosophies concerning Medicare reform, the legislation is tilted toward a catastrophic benefit and provides the greatest coverage to people with drug expenses of more than $5,100/year.  In the case of multiple sclerosis, it is common for individuals to spend more than $15,000 - $20,000 on drugs over the course of a year.

  • Drug Discount Card. Beginning in 2004, the Medicare bill authorizes new prescription drug discount cards in an effort to provide some assistance to beneficiaries until the Rx benefit takes effect. The US Department of Health and Human Services estimates that these cards could bring savings between 15% and 25% on prescription medications purchased at a pharmacies.

  • Transitional Coverage for MS Injectables.  Some Medicare coverage for people with MS who take one of the four injectable MS therapies may be available beginning in 2004 (see below).

  • Basic Benefit.  Voluntary Rx coverage would begin in 2006, with an average monthly premium of $35, and an annual $250 deductible.  Thereafter, Medicare would pay 75% of drug costs up to $2,250.  After $2,250 in drug costs are incurred, a coverage gap would exist until drug costs reach $5,100.  After this point, Medicare would pay about 95% of subsequent “catastrophic” drug expenses that year.  So, an individual with drug costs of more than $5,100/year, would pay about $3,525 out-of-pocket.  A person with drug costs of $20,000/year would pay about $4,275/year under the new benefit. 

  • Low Income Protections.  Under the agreement, individuals with incomes below 135% ($12,123/year) of the federal poverty level (FPL) generally would not pay premiums, deductibles or experience the gap in Rx coverage.  Additionally, beneficiaries with incomes between 135% of FPL and 150% ($13,470) of FPL would receive sliding scale Part D premium assistance.

  • Transitional Coverage for MS Injectables.  As reported, Society advocates have been working for over 18 months to secure immediate, transitional coverage for all four injected MS immunomodulating medications under Medicare.  Since August of 2002, Medicare only covers one of the four MS injectable therapies, if administered in a physician’s office.  For a beneficiary who cannot take the covered MS injectable, or cannot receive the injection in a physician’s office, Medicare coverage of all four MS therapies in any setting (e.g, at home) is critical.

The Medicare bill includes a two-year, $500 million demonstration project intended to cover certain drugs and biologicals in ’04 and ’05 – until the overall Medicare Rx benefit becomes effective in ’06.  This transitional coverage includes a 50,000 patient cap, subject to new Part D cost-sharing requirements.  This appears to be far more limited than we had hoped, but the exact nature of transitional coverage for people with MS is not yet clear.  By working closely with the administration on implementation, the Society will maintain efforts to provide comprehensive coverage for people with MS as quickly as possible.

Society advocates nationwide have worked especially hard over the past few months to include immediate MS coverage in the final Medicare bill.  Our sincere thanks to the 38 chapters who helped deliver the Society’s message to key congressional lawmakers and their aides over the course of the year.

Compromises.  The new Medicare agreement strikes a balance on a number of critical issues.  For example, the compromise includes about $86 billion in subsidies and tax advantages to encourage employers to continue providing drug coverage once the Medicare Rx benefit becomes effective.  Also, lawmakers amended a controversial House provision calling for nationwide direct price competition between traditional Medicare and private health plans – known as “premium support.”  The agreement includes a temporary, limited pilot project to test competition in up to six metropolitan areas beginning in 2010.  Also, in an effort to provide financial aid to the states, Medicare would pick-up the entire cost of covering all Medicare beneficiaries, including those who are covered under both Medicare and Medicaid (“dual eligibles”).

Other Medicare Improvements.  The Society also has been engaged in other areas of the Medicare reform legislation.  Over the past months, we have worked with the Consortium of Citizens with Disabilities and other patient and disability organizations.  As we understand it, we have persuaded legislators to oppose additional home-health co-payments, maintain a fair appeals process and coverage standards, and remove annual $1500 therapy caps on physical, speech, and occupational therapy services.

 

If you have questions or concerns please feel free to contact me directly at 1-800-FIGHTMS (1-800-344-4867) or via e-mail
jennifer.cramblett@ohg.nmss.org.

 

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Visit the Center for Medicare & Medicaid Services

 





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