Clinical Geriatrics

43 million people are eligible for Medicare Part D. Roughly 20% of the population of the United States.

Lost in the confusion and the difficulties with the implementation of Medicare Part D is the realization that the U.S. government, in its endless bureaucracy and politics, just enrolled 37 million people into a prescription drug benefit that will on average save a typical Medicare beneficiary $1100 per year.1 This was no small feat. It’s easy for pundits and experts to bemoan the barriers and difficulties of such an endeavor—but the reality is that it worked.

There will be no delay in the enrollment period or the penalty phase for most seniors, although some relief will be afforded to low-income individuals who miss the deadline.2 The communication and education, while accelerated, was pieced together and pulled together despite a seemingly directionless and haphazard approach. There is no precedent for this level of implementation. To be able to enroll this number of individuals and to have settled into a new drug benefit 150 days from implementation is profound. Some level of appreciation needs to be extended to the Centers for Medicare & Medicaid Services (CMS), the pharmacies, and the educators who brought the plan to the people. The shortcoming of the plan was the accelerated implementation period that was defined by Congress.

Only one small group of eligible Americans will pay more for their prescription drugs in 2006 than in 2005—and they are the lucky ones with few or no medication needs. What they get is insurance for the potential heart attack, stroke, or hip fracture that changes their medication requirements from few to many. In many cases, this insurance is less than $20 per month.3

As of May 11, 2006, only a small group of eligible Americans remained, prior to the May 15 deadline, without creditable coverage. In a press conference on May 10, 2006, Dr. Mark McClellan, administrator for the CMS, stated, “There are likely 3 million [remaining] people who are eligible for the low-income subsidy and for who we are going to continue to do outreach efforts before or after May 15.” The outreach to this population will continue, but there always will be those who choose not to enroll for one reason or another. Medicare Part D is voluntary.

Long-term care (LTC) residents were not targeted in the Medicare Modernization Act of 2003. Many of the issues affecting this population were not considered in the original legislation. Anyone familiar with lobbying the U.S. Congress understands that sometimes the scope of legislation does not address the diversity of the population impacted. This is the case with LTC. Only 2 million of the eligible 43 million seniors reside in skilled nursing facilities (SNFs), representing 4% of Medicare beneficiaries but using 25-50% of all Medicare Part D drugs.4 Therefore, special guidance from CMS coincided with the release of the implementation plan due to heavy advocacy for this population, and the specifics of that guidance have been realized in practice.

One such guidance is for dually eligible individuals living in LTC—those with both Medicare and Medicaid. A Special Enrollment Period (SEP) exists for residents who find themselves in prescription drug plans (PDPs) that do not provide the medications they need. This may occur upon admission or discharge from a SNF, or at any time during a SNF stay. The new plan that they choose would become effective the first day of the month following their enrollment, with the previous plan continuing coverage until that time. In some cases, it may be easier for nursing home residents and nursing home staff to change plans rather than endure a plan with restricted medications and prior authorization procedures.

Some identify the above scenario as a risk for SNFs that may be required to pay the cost of any noncovered medications.