Sorting out Medicare confusion

After five years of getting her prescriptions filled for no charge at her local pharmacy in Maple Valley, Estella Easterly, 84, says she recently was told she had to pay full price — or go without.

She couldn't prove that she had enrolled in one of Medicare's new Part D drug plans. Her insurance company hadn't sent her a membership card yet, and it set up her eligibility information improperly in the computer system. So Easterly — who lives on about $600 a month — paid what she could: $24 for a half-month's worth of one of her medications.

"I'm not one that cries very easily," said Easterly, a widow who used to get her drugs paid for by the government because of her low income. "If I can't get it straightened out, I'll just have to do without my medicines. I just can't afford that every month."

Easterly's frustration has become common as tens of thousands of Washington residents — especially the poorest of seniors and the disabled — have encountered a rough transition to the government's new prescription-drug plans.

About 24 million people nationwide now have signed up for one of the many drug plans offered by private health-insurance companies under contract with Medicare, including more than 2.6 million who have voluntarily signed up in the past 30 days. For many, the program is working well and saving them money.

But critics say a general lack of government preparedness for the avalanche of enrollees has meant that the program's first weeks since its Jan. 1 launch have been rife with confusion and delays.

How to get help


Advisers

The Statewide Health Insurance Benefits Advisors: 800-562-6900

The Medicare administration: 800-MEDICARE (800-633-4227)

The Senior Rights Assistance Program: 206-448-5720 or 888-435-3377 (ask for Senior Rights Assistance)

The National Asian Pacific Center on Aging offers information and assistance in several languages.

English and Chinese: 800-582-4218;

Korean: 800-582-4259;

Vietnamese: 800-582-4336

Online help

The Medicare Web site: www.medicare.gov

Other help

MedicareRxConnect, a coalition of nonprofit health organizations, has a comprehensive Web site to walk people through the process: www.maprx.info.

Washington Gov. Christine Gregoire last week wrote a letter to the Bush administration to demand "aggressive action."

The Bush administration Friday emphasized that all Medicare drug plans must provide transitional supplies of drugs and must cap charges to the poor at $5 per covered drug.

That has allayed concerns of some critics, who say the move will give beneficiaries and their plans some breathing room to untangle confusion. And many experts predict the situation will calm down before the May 15 deadline for voluntary sign-up.

But even so, "It's pretty chaotic and confusing for beneficiaries," said Tobi Johnson, program director for the state insurance commissioner's consumer help line. "I understand that other state health-insurance programs are reporting the same issues from consumers calling in to them."

Many beneficiaries nationally have been unable to get drugs, sometimes for critical conditions like heart disease, mental illness and diabetes. Often that's because the new drug plan they chose hasn't yet mailed them an identification card or put their enrollment information into their systems or the new plan simply doesn't cover the drugs they've been taking.

Meanwhile, a national computer system has been so overloaded that pharmacists have had trouble getting verification of customers' coverage. Even when they do get through, they are sometimes given erroneous information about the status of their coverage.

Help lines run by insurance plans — even the AARP's line — have been jammed with calls, and Medicare's Web site has been freezing up or booting users off.

States take action

In the midst of the confusion, more than a dozen states so far have taken emergency steps such as setting up special funds to assure that beneficiaries are able to get their critical medications.

The federal government won't reimburse states that choose to accept bills for Part D claims, but it will help the states recoup money from the private plan providers, said Michael Marchand, spokesman for the Centers for Medicare and Medicaid Services in Seattle.

Gregoire is evaluating the situation in Washington, which has not set up such a fund.

"But all options are being assessed," said Mark Rupp, executive policy adviser to the governor.

She wrote Friday to Mike Leavitt, Bush's secretary of Health and Human Services, warning the administration that "these issues, unless rapidly addressed, will hurt poor and disabled citizens — the weakest among us."

"The last thing any of us want to see is illnesses worsened by Part D implementation, and unnecessary deaths to follow," the governor wrote.

Gregoire also sent letters to drug plans approved in Washington, urging better communication. And she issued letters to the state's poorest beneficiaries, outlining their rights to get medications.

Washington's U.S. senators, Maria Cantwell and Patty Murray, have urged that the sign-up deadlines be extended beyond May 15.

"Dual eligible" problems

Still, a local spokesman for the federal Centers for Medicare and Medicaid Services (CMS) characterized the program's launch as "going well."

"As with any new program, it's not without its issues," said Michael Marchand, director of communications in Seattle. "The key is that we've been working really closely with the states, and the plans and the beneficiaries, to get people the critical medication they need."

Marchand said problems have been caused by "a huge influx of data" that arrived during the last two weeks of December as people began signing up for plans or switched from one plan to another.

CMS has set up regional assistance centers to provide immediate help for people who call the main 800-MEDICARE (800-633-4227) hotline and are in critical situations in which they aren't able to get lifesaving medication.

An emerging coalition of interest groups — including the AARP, Washington Citizen Action, the State Pharmacy Association and Northwest Health Law Advocates — is planning to try to get state funding for the new co-pays that have been imposed on the very poor under Medicare Part D.

Those are the people who have suffered the most immediate effects: the so-called "dual eligibles," about 6.2 million people across the nation and more than 100,000 in Washington who qualify for both Medicare and Medicaid.

Medicare is a federal health-insurance program for all people 65 or older, and disabled people. Medicaid is a government safety net for the very poor.

For dual eligibles, Medicaid has paid for their drugs until now. Under Medicare Part D, they were automatically and randomly assigned to a new plan. For the first time, they have to pay co-pays of between $1 and $5 per prescription.

Significant numbers of those very poor beneficiaries were assigned to plans that didn't cover all of the drugs they need. So many had to switch plans — or they only found out certain drugs weren't covered when they went to the pharmacy to get them.

Since the first of the year, the state has received from 200 to 300 calls a day from Medicaid clients having difficulties with Medicare Part D.

The federal government has set up a way for pharmacists to provide a temporary supply of drugs to certain low-income beneficiaries who are having serious difficulties with Part D.

But it doesn't apply in all cases. Sometimes, for whatever reason, consumers are still asked to pay the total price of their drugs out of pocket. Pharmacists generally don't let people leave without critical medication and will provide free transitionary drugs, but they often wonder whether the government will actually pay them back.

"Everybody says, 'Yes, you'll get paid,' " said Rod Shafer, CEO of the Washington State Pharmacy Association. "But you have to remember these same people said everything would run smoothly. It's unreasonable for the government to expect some of these small businesses to basically float these loans."

As for Estella Easterly, who is a dual-eligible beneficiary, she finally got all her medication, thanks to the help of an advocate from King County Senior Services and a pharmacy technician who spent hours on the phone straightening things out for her.

Finally, Easterly is now an official enrollee in Medicare's new system.

"It's been awful slow and frustrating," she said. "But I'm thankful I've got it."

Marsha King: 206-464-2232 or mking@seattletimes.com