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Policy Newsletter

May 19, 2006 | IN THIS ISSUE:

CMS Steps Up Enforcement of Part D Assistance Ban

Last week, we shared with you a CBS News story about the problems nursing home residents are having getting their drugs covered under Part D.  The story reported on how physicians who care for nursing home residents (most of whom are dual eligible and were auto-enrolled randomly in a Part D plan) have been overwhelmed by the amount of paperwork and phone calls required by some prescription drug plans to get drug coverage approved.  The report profiled a nursing home physician who cares for 300 duals and is spending almost half an hour on the phone in some cases to get a single drug approved by a plan.  And in some cases, the physician reports plans are directing him to prescribe medications that would be harmful to his patient’s health.

We also shared our concerns about CMS’ marketing guidelines, which prohibit physicians, pharmacists and nursing home staff from counseling nursing home residents about which drug plans best meet their needs.  We believe Medicare beneficiaries should be able to receive advice and assistance from their caregivers in evaluating and enrolling in a qualified Part D plan that best covers their medications. Those concerns were also expressed in a bipartisan Congressional letter sent to CMS Administrator McClellan recently as well.

Unfortunately, the day after we shared that with you, CMS sent a letter to State Survey Agency Directors – the regulators who conduct onsite inspections of nursing homes and enforce nursing home regulations – directing them to strictly enforce the prohibition on giving help to beneficiaries.   The letter tells the inspectors:

“Under no circumstances should a nursing home require, request, coach, or steer any resident to select or change a plan for any reason.  Furthermore, a nursing home should not knowingly and/or willingly allow the pharmacy servicing the nursing home to require, request, coach, or steer any resident to select or change a plan.”

LTCPA continues to believe there are many good and necessary reasons for nursing home Medicare beneficiaries to receive assistance from their caregivers.  Nursing home residents currently have the right to choose their own plan and they currently have the right to switch plans monthly in order to be enrolled in a plan that best matches their frequently changing medical needs.  LTCPA strongly supports those policies. However, unless their caregivers can inform beneficiaries when their drugs are not covered and help them evaluate whether another plan does a better job of covering their drugs, many will continue to lack the coverage Congress intended them to have.  

A copy of the latest CMS letter is available here.

For further information on this issue, please visit the LTCPA website at: ltcpa.org .  Also, please feel free to contact us if we can answer any questions or provide further information.


Darrell McKigney
Director of Government Affairs
Long Term Care Pharmacy Alliance