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Policy Newsletter

July 6, 2006 | IN THIS ISSUE:

LTCPA Analysis Finds CMS Prohibition on Caregivers Assisting Nursing Home Residents With Medicare Part D Plan Selection Is Creating Serious Problems

The Long Term Care Pharmacy Alliance (LTCPA), whose members include long term care (LTC) pharmacies which provide medicines to over one million of the nation’s nursing home residents, released a policy brief today outlining the problems that have been created by a federal prohibition on caregivers assisting nursing home residents in selecting a Medicare Part D plan. 

In its analysis, LTCPA finds:

  • Most nursing home residents are dual eligibles, who because of serious physical and mental impairments, did not choose their own Part D plan.  Instead, they were automatically enrolled by the federal agency which runs the Part D program, the Center for Medicare and Medicaid Services (CMS), into one of any number of plans at random, regardless of the whether the plan’s coverage matched the beneficiary’s drug needs.
  • Studies released this year by the U.S. Department of Health & Human Services, the Kaiser Foundation, and others have found Part D plans vary widely in their formularies and the restrictions they put on the drugs they cover.  The failure of a nursing home beneficiary to enroll in the plan that best matches their medication needs can have serious potential health consequences, as well as drive up the cost of coverage significantly.
  • The mismatching of nursing home residents with plans that do not best cover their drugs has created a number of serious problems. It has:  1) Made it difficult for many nursing home Part D beneficiaries to receive their prescribed medications, which can have a negative impact on their health. 2) Put a tremendous unnecessary administrative burden on physicians, nursing homes, pharmacists, prescription drug plans and CMS as they attempt to work around the problems created when a plan does not readily cover a beneficiary’s drugs. 3) Put a financial burden on nursing homes, pharmacies, prescription drug plans and the Part D program; one of which must assume the cost when drugs are not covered by readily covered by a particular plan. 4) Increased the cost of the Part D program by increasing administrative burdens; forcing plans to cover drugs for they have not negotiated the best price; and requiring the Part D program to pay for coverage of drugs a beneficiary is not likely to use.
  • Part D rules assume nursing beneficiaries need to change plans regularly due to their changing health needs.  That’s why Part D rules give dual eligible nursing home residents the special option to change plans monthly.  However, most are unable to exercise that option due to their poor physical and mental health.  Most would require the assistance of their caregivers in analyzing, choosing and enrolling in a Part D plan that best matches their drug usage.
  • A major hurdle for nursing home beneficiaries is the rules issued by CMS which prohibit caregivers including physicians, nursing home staff, and pharmacists from helping the nursing home residents they care for to compare, select and enroll in the best matching Part D plan. 

Those restrictions were set forth in CMS’ Part D Marketing Guidelines.  They were reinforced in a recent CMS directive to nursing home regulators which states: “Under no circumstances should a nursing home require, request, coach, or steer any resident to select or change a plan for any reason.” This restriction has made it difficult, if not impossible, for many nursing home Part D beneficiaries to enroll in or switch to a Part D plan that best covers their drugs.

Based on its analysis, LTCPA urges CMS to lift the prohibition on caregivers assisting nursing home beneficiaries in selecting a Part D plan.  Doing so would make it easier for nursing home beneficiaries to get their prescribed medications; as well as reduce the financial cost and administrative burdens for caregivers, prescription drug plans and the Part D program.

“The current prohibition on beneficiaries receiving help from their caregivers makes little sense and is causing tremendous problems for everyone involved, “said LTCPA Executive Director Paul Baldwin.  “Its time for CMS to change this policy.”

A copy of the full LTCPA analysis, “The Need to Change CMS Rules to Allow Caregivers to Help Nursing Home Residents Choose a Part D Plan,” is available at: ltcpa.org

Medicare Part D at Six Months: Issues for Beneficiaries in Long Term Care

LTCPA will be presenting a special briefing for congressional staff:

Medicare Part D at Six Months: Issues for Beneficiaries in Long Term Care
Monday, July 10, 2006
12:00 noon – 1:00 p.m.
B-369 Rayburn House Office Building

Please RSVP to Brenda Bishop: ,