Settlement on Medicare drug coverage for poor



Tens of thousands of low-income Americans who become eligible for Medicare each month should no longer have to wait weeks for subsidized prescription drug coverage under a new settlement with the Bush administration, lawyers in the case said Thursday.

The proposed settlement, submitted to a federal judge in San Francisco, would resolve a nationwide class action lawsuit filed on behalf of 6.2 million "dual eligibles" - people who were receiving health care through the Medicaid program for the poor when they became eligible for the federal Medicare program, open to those who are over 65 or have been disabled for two years.

Medicaid, funded by the federal and state governments, is known as Medi-Cal in California.

The suit focused on a gap between Medicaid, which provides prescription drug coverage, and Medicare, which began covering drugs through private health plans in 2006 in a program known as Part D.

When Medicaid patients become eligible for Medicare, they are supposed to be automatically enrolled in a health plan that continues their drug coverage. But according to the National Senior Citizens Law Center in Oakland, management problems have caused enrollment delays that last many weeks.

"People were left at the mercy of their pharmacists," said attorney Kevin Prindiville. "These are people who can't afford to shell out money for medication and get reimbursed afterward. A lot of pharmacists were very kind and provided temporary supplies, but (other patients) just had to find ways to get through the month, split pills, do whatever it takes."

He said the waiting period has decreased since the start of Part D, when more than 6 million dual-eligible patients moved into the program, but typically remains five to six weeks for the tens of thousands of Medicaid recipients who transfer to Medicare each month.

The settlement requires the government to change its computer system and allow the state to submit the names of new low-income Medicare beneficiaries more than once a month, eliminating a major cause of delay, Prindiville said. Those reports would have to be processed within a day.

Another change involves the Medicare subsidy that allows former Medicaid patients to get prescription drugs for no more than $3.10, rather than the co-payments of $50 or more that private health plans often charge, Prindiville said.

The lawsuit said many patients were being denied subsidies because they lacked the needed documents, or because health plans failed to inform pharmacists of their eligibility. The settlement requires a health plan to contact Medicare about the status of a patient who claims a subsidy but lacks documentation, and mandates an immediate response when the patient is nearly out of medication.

"These individuals have faced life-threatening delays in receiving vital medication," Prindiville said. "We view the administration's agreement to this settlement as a sign that it is now committed to providing adequate protections."

Jeff Nelligan, spokesman for the federal Centers for Medicare and Medicaid Services, said in a statement that the agency, since the start of Medicare Part D, "has worked tirelessly to ensure that all enrollees, including those dually eligible for Medicare and Medicaid, have full and timely access to the prescription drugs they need." He declined comment on the settlement.

If approved by U.S. District Judge Thelton Henderson, the settlement would require the agency to make the needed changes to its computer system by Aug. 31 and would remain in effect for three years.