| | Huntington, New York 11743
April 28, 2006
Representative Nancy L. Johnson
House Ways and Means Committee
Health Subcommittee
1100 Longworth House Office Building
U.S. House of Representatives
Washington, D.C.
Dear Representative Johnson:
I am a twenty-eight year old woman with cognitive
and psychiatric disabilities living in Long Island, New York. I would like to
share my experiences regarding the Medicare Part D benefit as part of the May 3, 2006 hearing. As a “dual eligible” receiving benefits from both Medicare and
Medicaid, I have experienced numerous difficulties stemming from the new
benefit.
I fervently wish that Part D had not come into
existence. I take ten prescription medications, and was much better off when they
were covered by Medicaid. During the many years when I received drug coverage
through Medicaid, I fell into a special category and thus paid no copays at
all. My sole sources of income are SSI and SSDI, and even the small copays
required under Part D have forced me to rearrange my budget, leaving less money
available for such necessities as groceries and clothing.
While I am in fact losing money under Part D,
the government has arbitrarily determined that I am saving money. As “everyone”
is “obviously” benefiting”, my food stamps have been reduced. The judgment that
I can afford this was arbitrary. Evidently, I am being “lumped” into a category
with many others, with no effort to investigate my situation. My need of a
subsidy to help pay for Part D hardly implies that I need no further assistance
from the government.
Since my Medicaid prescription drug
coverage ended December 31, 2005, my participation in Part D was made mandatory.
Were I have opted out of Part D, I would have lost my Medicaid benefits, though
I was better off beforehand. How can people like me obtain independence if the
option to pick and choose individually appropriate benefits is removed? The
government automatically enrolls dual eligibles in a plan with a premium below
their region’s benchmark. A plan is randomly selected; no regard is given to
the medications taken by the enrollee or the pharmacy s/he uses. Not
surprisingly, the plan into which I was auto-enrolled included neither my pharmacy
in its network nor covered all of my medications, so I was forced to switch. It
seems to me that the government is not particularly concerned about placing dual-eligibles
in plans suiting our needs. Rather than make the effort to assist people like
me with appropriate placement, officials have merely ducked their
responsibilities and have decided to funnel us into plans. If we are not happy
with them, it is our responsibility to change, because the government has
“taken the easy way out.”
Meanwhile, I was making phone calls
and conducting research. Even though I had automatically eliminated plans above
the benchmark, I still had many others to investigate. I had a great deal of
difficulty sorting out the information. The process took me three or four
months due to the complexity of the situation and the problems I encountered.
For instance, I found that the CMS Formulary Finder often listed a drug as covered
by a plan and was thus at odds with the plan website. In other instances, there
was a discrepancy between the two regarding the use of drug utilization
management techniques (quantity limits, step therapy, prior authorization) for
a drug. I had to create numerous charts and lists of my own in order to keep
track of all the information.
Some of the plans had to be rejected
because their formularies indicated that they did not cover some of my antipsychotic
or antidepressant medications, even though CMS has determined that all of these
medications must be covered. Other plans did cover them, but used drug
utilization management techniques to manage their use. It is my understanding
that plans are not permitted to apply these techniques to drugs in certain
categories (including antidepressants and antipsychotics), with few exceptions.
Since CMS supervises and manages Part D, it is responsible for ensuring that
the plan sponsors adhere to the regulations it establishes.
Since I am eligible for a full subsidy, I called
plans in order to determine my copays. Many plan websites did not include the
information. Some were not even working as of November 15, the first date of enrollment.
Due to a misunderstanding, I mistakenly believed that I would have different
copays under different plans. Many of the people I spoke to did not know how
much I would pay, or the information differed from plan to plan or even between
two representatives of the same plans. The matter was eventually clarified. Additionally,
when discrepancies between the Formulary Finder and plan websites necessitated
a phone call, different representatives from the same plan would supply me with
different information. This is indicative of a lack of coordination between CMS
and the private insurance plans, as well as among the plan employees
themselves, and that is inexcusable.
Once I had selected a plan, the United
Healthcare-sponsored Medicare MedAdvance, I enrolled online. Although I
received a letter from the plan shortly after, I did not receive my plan
identification card until midway through January 2006. No attempt was made to
prioritize the applications of dual eligibles such as myself, even though the
benefit started for me on January 1st, 2006, as my Medicaid drug
coverage ended on December 31, 2005. In contrast, non-dual eligibles did not
need to start using Part D on January 1st. It took a phone call to
MedAdvance – during which I was placed on hold for forty-five minutes, though
federal requirements state phone calls must be answered within a reasonable
time period – to confirm that CMS had not yet finished processing my
application! Fortunately, the representative eliminated a major worry by informing
me that I could use the letter from the plan as proof of (pending) membership.
I should not have had to go to such lengths to confirm the letter’s validity
just to ensure that I could obtain my medications even without my
identification card.
In addition, I am frustrated about the lack of
attention given by MedAdvance to maintaining its website. A newsgroup e-mail
alerted me to a change in coverage regarding two prescription forms of niacin.
Originally deemed ineligible for coverage because they are vitamins, CMS has
changed its mind because these medications can be covered at the plan’s
discretion because they are used to treat high cholesterol. I should like to
discuss taking one of these medications with my doctor, but I wanted to
determine whether or not the plan covers them. The section of the MedAdvance
website detailing formulary changes has not been updated since March 2006,
while permission for coverage of the drugs was granted by CMS in April 2006. In
terms of efficiency, especially considering the wait time during phone calls to
MedAdvance, obtaining the information via website is usually easier than making
a phone call. However, the website information is not current. Additionally, I am
having some difficulty trusting the plan representatives to provide current and
accurate information, given my experiences with various personnel while I was
choosing a plan in which to enroll.
Based on my own experiences, I have determined
that Medicare Part D is not a boon but a blight upon our country. Although I
was able to research and choose a plan of my own, I experienced a great amount
of difficulty while doing so, and have had further problems with the
prescription drug benefit. I would like to point out that many individuals were
not and are not able to research and choose plans themselves, nor to navigate
the maze after enrollment. Many seniors are uninformed or lack my computer
skills; dual-eligibles may often have impairments too severe to enable them to
effectively advocate for themselves in this particular situation.
If the level of civilization within
a society is gauged according to the treatment given its vulnerable populations
– both the disabled and the elderly may be considered as such – then Part D is
a mark against the United States Government and against the insurance and
pharmaceutical companies of America. In the future, more attention must be paid
to the individual needs of beneficiaries. Efforts should be made by both the
government and the insurance and drug companies to improve communications
within and between companies and the government, and with beneficiaries. The
government ought to cease to dictate terms to the disabled and the elderly
through regulations purporting to be in our best interests, therefore robbing
us of the independence to which we are entitled.
Thank you for your time and attention.
Yours
truly,
Jessica
Miller
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