Bay Area Reporter - November 23, 2006
Heather Cassell, h.cassell@ebar.com

Medicare is encouraging people to enroll by December 8 to ensure they have a smooth transition to obtain their medications by the New Year. This doesn't leave much room for people to review and comprehend the new plans. Companies have consolidated some plans, changed the names of others, and replaced or eliminated some plans altogether.

The companies have also altered eligibility requirements - especially for an estimated 30 to 40 percent of low-income subsidy clients in California who may no longer meet the new requirements. The new criteria requires them to select a new plan that may mean paying higher premiums and increased co-pay rates for decreased benefits.

In order to prepare social workers, healthcare professionals, and benefit counselors to assist their clients in deciphering which plan works best for them, the San Francisco AIDS Foundation, Project Inform, and the East Bay Community Law Center partnered on November 16 to provide a comprehensive overview of Part D's dramatic changes.

"I don't think that my clients anticipated that it would be like starting over," said Ellen Novogradsky, a financial benefits counselor for SFAF, her brow furrowed as tears welled up in her eyes. "My clients are very anxious, very stressed about the changes and they are happening really quickly ... their stress and anxiety is justified ... there's a fear people will have difficulty getting medications."

There are 55 plans run by private insurance companies, but they are all different. Even if someone has been automatically rolled over into a plan for 2007 it doesn't mean that the plan will continue to provide the same amount of benefits that they had previously. If someone has already enrolled in a plan it could change by January 1, 2007 or after the enrollment period has closed.

While the plans can change at will, they do have to provide a 60-day notice for any changes, but not all plans provide a transition supply of medications. There are certain eligible classes that won't change, according to Anne Donnelly, director of healthcare and advocacy for Project Inform and the lead presenter at the forum: individuals with standard plans won't change; dual eligibility (meaning clients can be enrolled in both Medicare and Medicaid) can always change; people with dual eligibility with a share of cost (people whose plans have a premium) can change sometimes; and those who lose their low-income subsidy in January will have a special three-month enrollment period.

There are six protected AIDS classes this year, as there were last year, but it is not guaranteed they will exist in 2008. The classes may be reduced or dropped, said Donnelly. AIDS advocates are asking Congressional leaders to ensure the classes will remain and are seeking Speaker-elect Nancy Pelosi's (D-San Francisco) support.

A spokesman for Pelosi stated that the enrollment period should be longer.

"It is unacceptable that they have to enroll by December 8 or run the risk of being cut off from their prescription benefits on January 1, 2007," said Drew Hammill in Pelosi's press office. "Medicare is not being fair. There is a better way, and a Democratic Congress will bring desperately-needed oversight to this program."

Hammill stated, "Speaker-designate Pelosi has indicated that in the first 100 legislative hours of the 110th Congress, the House will pass legislation that will allow the secretary of Health and Human Services the ability to negotiate for lower drug prices. There will also be more oversight of this program in the next Congress that will work to ensure the Medicare prescription drug program is working smoothly and to eliminate further confusion for beneficiaries."

Hammill continued, "Studies have shown that Medicare beneficiaries will continue to face problems with this complicated and confusing program. Most troubling is that, unlike most forms of insurance, the Medicare prescription drug program has an enormous coverage gap. The bottom line with this program is that it's not serving the needs of our seniors and others who rely on the program."

Donnelly is also highly critical of private companies' handling of low-income clients.

"Private plans just don't know how to service this population in a correct way," she said. "Because it's a population that has more illness, has more cognitive issues, typically language and cultural barriers, so it's a very different population and that's one of the fatal flaws of this Medicare debacle."

In order to survive the changes and the tight enrollment period, Donnelly strongly encourages people to take the following steps:

* Review your plan to make sure that it's still working to provide the benefits you need both with medical and prescription coverage, but also with the pharmacy network. Also, check other plans to see if they might work better. Narrow the plans down to the three that will work best for you.

* Contact your healthcare benefits provider or locate one immediately to help you with your questions, the enrollment process, and who might know about alternative benefit programs you may not be aware of. For example, there is the Working Well Disabled program, which eliminates a patient's share of cost and enables Medicare to cover other medical costs for those who are eligible.

* If you don't receive the full low-income subsidy and are eligible for Medicare, contact the AIDS Drug Assistance Program to find out information about its new ADAP Medicare Premium program.

* Look to your pharmacist as an advocate and a resource.

"Our clients absolutely need to understand their benefits. It's past the point that we can protect them from the gaps in their benefits, so if they don't recognize that they've met their share of cost and they are not watching for that [low-income subsidy] you may never know about it," said Donnelly.

"It behooves everyone to be their own advocate and there are plenty of resources in San Francisco if people seek them out," added Ken Pearce, a trained volunteer who has been with Project Inform for about three years. "I feel strongly about peer support programs because I think there are a number here in the city ... the AIDS Health Project is probably one of the biggest ones where people with HIV and AIDS can [go to a session] once a week with other people in an anonymous safe environment and it's amazing what you can learn from people who've already been through it."

No matter what happens, on January 1 people should not leave their pharmacy without their medications; backup systems are in place to protect them. Donnelly stated that the Centers for Medicaid and Medicare Service have said that no dual or low-income subsidy person should leave the pharmacy without their medication. If problems arise they should seek out advocacy support right away. People do have some rights, particularly those on low-income subsidy, during the transition between plans. As a last resort people can check with the pharmaceutical companies that make their prescription drugs to see if they have and are eligible for their patient assistance programs.

When asked by the Bay Area Reporter if the healthcare system could make providing basic benefits easier for low-income people, Donnelly simply stated, "Yes, it is universal care."

Medicare Part D health benefits information

AIDS Hotline 800-367-AIDS www.sfaf.org/aidsinfo/basics/hotline.html

ADAP Medicare, State office of AIDS www.dhs.ca.gov/AIDS

Centers for Medicare and Medicaid Services 800-633-4227 www.cms.hhs.gov/

Families USA 202-628-3030 www.familiesusa.org

Gay Men's Health Crisis 800-243-7692 www.gmhc.org/hotline.html

The Health Consumer Alliance (310) 204-4900 healthconsumer.org/

Health Initiatives for Youth (415) 274-1970 www.hify.org/wide_wide_world.htm

Health Insurance Counseling and Advocacy Program/ State Health Insurance Assistance Program 800-434-0222 www.calmedicare.org/counseling/index.html

HIV Medicine Association (703) 299-1215 www.idsociety.org/HIVMA_Template.cfm

Medicare 800-633-4227 TTY 877-486-2048 www.medicare.gov

Medicare Advocacy www.medicareadvocacy.org

National Senior Citizens Law Center (510) 663-1055 www.nsclc.org

Positive Resources Center (415) 777-0333 positiveresource.org/benefits/default.asp

Project Inform 800-822-7422 www.projinf.org/org/infoline.html

Treatment Access Expansion Project www.taepusa.org/medicare_resources.html

WORLD (510) 986-0340 www.womenhiv.org/index.html

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