02.02.06

Cantwell Vows to Continue Fight after Much-Needed Medicare Drug Program Fails by Narrow Margin

Legislation would have extended enrolment deadline, eliminated coverage gaps, helped seniors get life-saving drugs

WASHINGTON, DC – Thursday, U.S. Senator Maria Cantwell (D-WA) vowed to continue the fight to get seniors the care they need and pass a fix for the troubled Medicare prescription drug program. The Requiring Emergency Pharmaceutical Access for Individual Relief (REPAIR) amendment, co-sponsored by Cantwell, failed to pass the Senate by eight votes late on Thursday night. The amendment also included a provision Cantwell has been seeking which would extend the enrollment deadline for the new Medicare prescription drug program through the end of 2006.

“Unless we act, seniors across Washington state will continue facing higher costs and inadequate coverage,” said Cantwell. “Seniors deserve a drug program that doesn’t fail our sickest and poorest. We had an opportunity to get seniors the medicine they need, but the Senate failed to act. I’ve heard far too many stories of people going without life-saving drugs because of the gaps in this confusing program. We need to fix this program now and I will keep pushing until we get the job done.”

Thursday night, the Senate rejected the REPAIR Act, which was offered as an amendment to the Tax Reconciliation bill. Earlier this month, Cantwell joined Senator Jay Rockefeller (D-WV) to introduce this legislation to eliminate gaps in prescription drug coverage and provide life-saving medications to low-income and disabled seniors left behind by the new Medicare program. While supported by a majority of Senators by a vote of 52-45, under Senate floor rules the legislation required 60 votes to pass as an amendment on Thursday night.

Seniors eligible for both Medicare and Medicaid often have chronic illnesses and the lowest incomes. These “dual eligibles” were automatically assigned to drug plans based on zip code, with no regard for which plan would actually fit them best. Dual eligibles who decide to switch plans are not covered by the new plan until the first day of the following month, leaving many without access to medications for up to 30 days. In many cases, dual eligibles have encountered higher premiums and problems changing plans, leaving them without necessary medicine for even longer. The REPAIR act would address this gap by guaranteeing seniors access to a 30-day transitional supply of prescription drugs.

Pharmacies have also had difficulties accessing necessary information from Centers for Medicare and Medicaid and have often covered the cost of giving seniors needed medications themselves. There are over 96,000 dual eligibles in Washington state.

[Highlights of the REPAIR Act follow below]

To guarantee access to prescription drugs, the REPAIR Act would:

  • Require plans to include in their transition policies a 30-day supply of prescription drugs beneficiaries were taking prior to their enrollment in their new plan. This policy applies would apply to new Medicare enrollees as well as to beneficiaries who switch plans.
  • Assume eligibility for dual eligibles at the point-of-sale who present a government-issued picture identification card, their Medicaid card, and reliable evidence of Medicare enrollment. Presumptive eligibility would apply when pharmacists cannot verify dual-eligible status through the E-1 billing system or the point-of-sale plan. Pharmacists can then bill CMS directly for these prescriptions.
  • Require CMS to clearly identify dual eligibles and share the information with prescription drug plans and ensure that pharmacists have access to the information during E-1 queries and point-of-sale encounters.

To protect low-income Medicare beneficiaries, the REPAIR Act would:

  • Prohibit states from conditioning Medicaid eligibility on enrollment in Medicare Part D for individuals who have other forms of insurance count as credible coverage under Medicare Part D, including employer-sponsored retiree coverage and Veterans health benefits.

To improve CMS customer service, the REPAIR Act would: 

  • Require CMS to station one trained employee at every State Health Insurance Program (SHIP) through the open-enrollment period to help beneficiaries and SHIP counselors better understand the Medicare drug benefit.
  • Require CMS to hire additional trained professionals to reduce 1-800-MEDICARE wait times.

To reduce the burden placed on pharmacies, the REPAIR Act would:

  • Require CMS to provide additional outreach and education to pharmacies unaware of the E-1 billing system and how to use it, particularly independent pharmacies in rural parts of the country.
  • Reimburse pharmacies for any transaction fees related to the point-of-sale enrollment process and technology or software upgrades necessary to make identification and enrollment inquires.
  • Allow pharmacies to bill CMS directly for the costs of providing a transitional supply of prescription drugs to dual eligibles. Pharmacies will be able to bill CMS directly for the costs associated with providing a transitional supply of prescription drugs to dual eligibles presumed eligible based on the standards listed above and for which pharmacies are unable to get verification of status from the E-1 billing system or point-of-sale plan.

To provide federal reimbursement to states and beneficiaries, the REPAIR Act would:

  • Require CMS to compensate to dual eligibles incorrectly charged premiums, deductibles, or other cost-sharing. Dual eligibles incorrectly charges premiums or deductibles. Beneficiaries will receive refunds directly, either through a direct payment or a rebate on future Social Security checks.
  • Requires CMS to provide full reimbursement to states incurring unexpected costs filling the gaps in the Medicare drug program in 2006.
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