NAVIGATING THE MEDICARE MAZE - Part B plus Part D equals a mess
NAVIGATING THE MEDICARE MAZE
Part B plus Part D equals a mess
Confused about new drug benefit, pharmacists and administrators stick patients with the bill
By Judith Graham, Tribune staff reporter. The Associated Press contributed to this report
Published March 15, 2006. Copyright by The Chicago Tribune
Frank Cartalino, a transplant patient, was distraught. No one could tell him why his pharmacy had suddenly billed him $500 for the drugs he needs to stay alive.
An Illinois program had covered the expense for years. Now, Cartalino had a letter saying the program had changed and he needed to get the medications through a Medicare drug plan. But the plan was refusing to pay the bill.
Cartalino called Medicare's national hot line repeatedly. He called an insurance company working with the Illinois program. He called Humana Inc., his Medicare drug plan. He called drug companies, begging to get on their financial assistance programs. No one, it seemed, was able to help.
Then, Cartalino, 42, who lives on a fixed income, undergoes dialysis three times a week, and takes drugs that prevent his body from rejecting a double organ transplant, called the Chicago Tribune.
Days of research revealed the root of his problem: Staff members working with pharmacies, insurance plans and government agencies don't really understand how Medicare's new drug benefit coordinates with other parts of the vast health program. And thousands of patients with organ transplants and other illnesses are getting caught in the middle.
On Tuesday, President Bush defended the prescription drug benefit as a good deal for seniors and taxpayers. But he acknowledged that the program had been plagued by problems in its early days.
"Anytime Washington passes a new law, sometimes the transition period can be interesting," the president said.
Interesting isn't the word senior citizen advocates use to describe it.
"It's an enormous mess. ... a real nightmare," said Jeanne Finberg, an attorney at the National Senior Citizens Law Center.
The risk, of course, is that patients won't get needed medications because of mix-ups or, like Cartalino, they'll end up paying for expensive drugs out of limited personal funds.
The government recognizes this is a serious matter, and officials have been busy clarifying policies and consulting with medical providers, pharmacists, drug plans and advocates, said Dr. Jeffrey Kelman, chief medical officer for Medicare's Center for Beneficiary Choices. It has been a learning experience, he said.
That's something of an understatement. It took more than a dozen phone calls for the Tribune to sort through the mind-numbing complexities of Medicare and figure out where things had gone wrong for Cartalino, who lives in southwest suburban Worth.
This is the issue: Two parts of Medicare, known in bureaucratese as Part B and Part D, now cover drugs. But there's no simple way to describe which program covers what drugs for which patients. As a result, some pharmacists and many customer service representatives are getting Part B and Part D mixed up.
Part B covers a limited number of medications administered primarily in doctors' offices and nursing homes. Part D covers a much broader universe of medications, including those most people take for common medical conditions. If Part B picks up the bill for a medication, Part D coverage isn't supposed to pay, to prevent double billing.
In practice, the way the Medicare programs interact is anything but straightforward, Kelman said.
Take methitrexate, a drug that can be used to treat transplant patients as well as patients with cancer or rheumatoid arthritis. Part B will pay for the medication for transplant and cancer patients, but not for people with arthritis. That falls to Part D.
Another example: Part B will pay for albuterol, a medication taken by people with asthma, when it's administered by nebulizer, a machine that sprays medicine into the mouth, in a person's home. But if a senior citizen with asthma gets albuterol through a nebulizer in a nursing home, the medication is covered by Part D. And if albuterol comes in a hand-held unit, it's also a Part D benefit.
There's more: If a patient gets a transplant while on Medicare, like Cartalino did, Part B will pay for anti-rejection medication. But if a patient wasn't on Medicare at the time, Part D will pay for the drugs.
That's part of what tripped up Cartalino and the many people who tried to answer his questions this year. But there were other factors.
The Illinois Comprehensive Health Insurance Plan, ICHIP, sent out misleading material to Cartalino and about 1,000 other disabled Medicare patients in October and December.
ICHIP is a program for state residents who can't get health insurance through traditional channels because of pre-existing medical conditions. For people like Cartalino who have Medicare, ICHIP pays for medical charges that Medicare doesn't cover in full.
Because of changes in Medicare, ICHIP informed members that it would stop paying for all prescription drugs. The letters urged people to sign up with a new Medicare drug plan so they would still get some help with medication expenses.
Nowhere did the ICHIP letters mention that the program would still pay for a limited set of drugs under Medicare Part B. (Medicare pays 80 percent of the cost of these drugs; ICHIP had been paying the remaining 20 percent.) That was explained but not highlighted in ICHIP's annual explanation of benefits.
That's the equivalent of asking someone to read the fine print buried on a drug label--no one does it.
When Cartalino got ICHIP's letter, he went shopping for a Medicare drug plan. After careful research, he decided on a Humana plan that promised to supply the medications, Prograf and Rapamune, which together cost nearly $2,500 a month.
But when it came time to fill his anti-rejection prescriptions, Cartalino learned that the Humana plan wouldn't authorize payment because the drugs were deemed a Part B, not a Part D, benefit.
Cartalino, a former printer who lives alone on a fixed monthly income of $2,000, scrambled to find almost $500--the monthly amount ICHIP had been paying previously for the medications. Then he began working the phones, but no one could answer his questions.
Poor training of customer service representatives at every level appears to be a real problem. Each time Cartalino called, he reached people who didn't understand his situation or who didn't know how to help him.
A Tribune reporter encountered the same difficulties. Medicare, drug plan, and ICHIP officials all say they've worked hard on training customer service staff.
With the intervention of Robert Herskovitz, a Chicago Medicare official, Cartalino finally learned that ICHIP would cover his transplant drugs after all. It had been in the policy all along, though materials didn't make that clear.
The good news in all this is that Medicare's new drug benefit, Part D, fills an important gap for seniors who have had transplants but no way previously of paying for drugs for conditions such as high cholesterol or hypertension.
Cartalino is now getting his anti-rejection medications without any problem after weeks of getting the runaround.
"Thank God," he said. "Without this help, I just couldn't have made it."
Part B plus Part D equals a mess
Confused about new drug benefit, pharmacists and administrators stick patients with the bill
By Judith Graham, Tribune staff reporter. The Associated Press contributed to this report
Published March 15, 2006. Copyright by The Chicago Tribune
Frank Cartalino, a transplant patient, was distraught. No one could tell him why his pharmacy had suddenly billed him $500 for the drugs he needs to stay alive.
An Illinois program had covered the expense for years. Now, Cartalino had a letter saying the program had changed and he needed to get the medications through a Medicare drug plan. But the plan was refusing to pay the bill.
Cartalino called Medicare's national hot line repeatedly. He called an insurance company working with the Illinois program. He called Humana Inc., his Medicare drug plan. He called drug companies, begging to get on their financial assistance programs. No one, it seemed, was able to help.
Then, Cartalino, 42, who lives on a fixed income, undergoes dialysis three times a week, and takes drugs that prevent his body from rejecting a double organ transplant, called the Chicago Tribune.
Days of research revealed the root of his problem: Staff members working with pharmacies, insurance plans and government agencies don't really understand how Medicare's new drug benefit coordinates with other parts of the vast health program. And thousands of patients with organ transplants and other illnesses are getting caught in the middle.
On Tuesday, President Bush defended the prescription drug benefit as a good deal for seniors and taxpayers. But he acknowledged that the program had been plagued by problems in its early days.
"Anytime Washington passes a new law, sometimes the transition period can be interesting," the president said.
Interesting isn't the word senior citizen advocates use to describe it.
"It's an enormous mess. ... a real nightmare," said Jeanne Finberg, an attorney at the National Senior Citizens Law Center.
The risk, of course, is that patients won't get needed medications because of mix-ups or, like Cartalino, they'll end up paying for expensive drugs out of limited personal funds.
The government recognizes this is a serious matter, and officials have been busy clarifying policies and consulting with medical providers, pharmacists, drug plans and advocates, said Dr. Jeffrey Kelman, chief medical officer for Medicare's Center for Beneficiary Choices. It has been a learning experience, he said.
That's something of an understatement. It took more than a dozen phone calls for the Tribune to sort through the mind-numbing complexities of Medicare and figure out where things had gone wrong for Cartalino, who lives in southwest suburban Worth.
This is the issue: Two parts of Medicare, known in bureaucratese as Part B and Part D, now cover drugs. But there's no simple way to describe which program covers what drugs for which patients. As a result, some pharmacists and many customer service representatives are getting Part B and Part D mixed up.
Part B covers a limited number of medications administered primarily in doctors' offices and nursing homes. Part D covers a much broader universe of medications, including those most people take for common medical conditions. If Part B picks up the bill for a medication, Part D coverage isn't supposed to pay, to prevent double billing.
In practice, the way the Medicare programs interact is anything but straightforward, Kelman said.
Take methitrexate, a drug that can be used to treat transplant patients as well as patients with cancer or rheumatoid arthritis. Part B will pay for the medication for transplant and cancer patients, but not for people with arthritis. That falls to Part D.
Another example: Part B will pay for albuterol, a medication taken by people with asthma, when it's administered by nebulizer, a machine that sprays medicine into the mouth, in a person's home. But if a senior citizen with asthma gets albuterol through a nebulizer in a nursing home, the medication is covered by Part D. And if albuterol comes in a hand-held unit, it's also a Part D benefit.
There's more: If a patient gets a transplant while on Medicare, like Cartalino did, Part B will pay for anti-rejection medication. But if a patient wasn't on Medicare at the time, Part D will pay for the drugs.
That's part of what tripped up Cartalino and the many people who tried to answer his questions this year. But there were other factors.
The Illinois Comprehensive Health Insurance Plan, ICHIP, sent out misleading material to Cartalino and about 1,000 other disabled Medicare patients in October and December.
ICHIP is a program for state residents who can't get health insurance through traditional channels because of pre-existing medical conditions. For people like Cartalino who have Medicare, ICHIP pays for medical charges that Medicare doesn't cover in full.
Because of changes in Medicare, ICHIP informed members that it would stop paying for all prescription drugs. The letters urged people to sign up with a new Medicare drug plan so they would still get some help with medication expenses.
Nowhere did the ICHIP letters mention that the program would still pay for a limited set of drugs under Medicare Part B. (Medicare pays 80 percent of the cost of these drugs; ICHIP had been paying the remaining 20 percent.) That was explained but not highlighted in ICHIP's annual explanation of benefits.
That's the equivalent of asking someone to read the fine print buried on a drug label--no one does it.
When Cartalino got ICHIP's letter, he went shopping for a Medicare drug plan. After careful research, he decided on a Humana plan that promised to supply the medications, Prograf and Rapamune, which together cost nearly $2,500 a month.
But when it came time to fill his anti-rejection prescriptions, Cartalino learned that the Humana plan wouldn't authorize payment because the drugs were deemed a Part B, not a Part D, benefit.
Cartalino, a former printer who lives alone on a fixed monthly income of $2,000, scrambled to find almost $500--the monthly amount ICHIP had been paying previously for the medications. Then he began working the phones, but no one could answer his questions.
Poor training of customer service representatives at every level appears to be a real problem. Each time Cartalino called, he reached people who didn't understand his situation or who didn't know how to help him.
A Tribune reporter encountered the same difficulties. Medicare, drug plan, and ICHIP officials all say they've worked hard on training customer service staff.
With the intervention of Robert Herskovitz, a Chicago Medicare official, Cartalino finally learned that ICHIP would cover his transplant drugs after all. It had been in the policy all along, though materials didn't make that clear.
The good news in all this is that Medicare's new drug benefit, Part D, fills an important gap for seniors who have had transplants but no way previously of paying for drugs for conditions such as high cholesterol or hypertension.
Cartalino is now getting his anti-rejection medications without any problem after weeks of getting the runaround.
"Thank God," he said. "Without this help, I just couldn't have made it."
posted by Carlos T Mock at 10:18 AM
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