September 07, 2004

New Medicare Rules May Affect You

New Medicare drug-benefit rules in the USA may impact You - The Government is Seeking Public Feedback.

The Medicare Modernization Act, enacted last year and taking effect in
January 2006, represents a fundamental change in the 40-year-old entitlement program. It creates a $ 400 billion prescription drug benefit for elderly people and some people with disabilities and gives private insurers a huge new role. For the first time, private-sector drug plans will administer the benefit
through a competitive model

One big issue for the mental health field is the way the benefit will treat people who quality for both Medicare and Medicaid. Called "dual eligibles," these beneficiaries are thought to number about 6.4 million. Up to 40 percent are estimated to have a serious mental illness such as bipolar disorder or schizophrenia. Currently, only Medicaid carries a prescription drug benefit for them.

Dually eligible beneficiaries will see their drug coverage shift from Medicaid to Medicare over time.

The National Alliance for the Mentally Ill (NAMI), worries that dually eligible beneficiaries could find their drug access more limited than it is now. This could happen if the formularies allowed under Medicare are more restrictive than the drug coverage that beneficiaries could obtain through Medicaid, or if the Medicare formularies fail to include a drug that has been covered through Medicaid.

"NAMI would like to see a continuity-of-care requirement" that would
prohibit the new Medicare plans from denying people effective medication as they make the transition from Medicaid, Andrew Sperling, NAMI's director of federal legislation stated recently.

"At the very least, the regulations must ... 'grandfather in' this coverage," states a letter from NAMI to CMS Administrator Mark B. McClellan, M.D., Ph.D.

The notice currently does not contain such a requirement. NAMI will work to
see that such a requirement is added and will work to ensure that the new
regulations allow the greatest access to the broadest range of treatments for mental illness.

Another big issue for the field involves the way that drug formularies will
be devised for the new Medicare plans. The regulations and law allow for health
insurers to use Pharmacy and Therapeutics Committees to design their formularies and coverage plans. The committees' composition and authority, and the requirement that they must be independent and free of conflict of interest, are discussed in the notice.

But the regulations don't require the committees to conduct their business
in "an open, transparent process with public meetings," according to NAMI. "We'd like to see openness and transparency in the process," Sperling said.

A highlight in the regulations, Sperling said, is CMS's decision to name the
U.S. Pharmacopeial Convention, Inc. (USP), of Rockville, Md., to develop model
guidelines to be used as a framework for insurers as they design their
prescription drug formularies. The guidelines will include therapeutic
categories and classes of drugs to be covered.

For more information, see Centers for Medicare & Medicaid
Services, at:


Post a comment

Please enter this code to enable your comment -
Remember Me?
(you may use HTML tags for style)
* indicates required