November 26, 2024
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Drug plan ‘horror show’ slowly ‘getting better’

BANGOR – The rollout of the new federal prescription benefit this week has been a “horror show,” according to Bill Miller, owner of Miller Drug on State Street. But, he added quickly, “every day it’s getting better,” and he credits the state’s health office with providing responsive and effective support to frustrated pharmacies and consumers.

“Our state government in Augusta has been working all weekend and late into the night doing an outstanding job to see that the most fragile of our citizens are taken care of,” Miller said – uncommon praise from a politically active professional often at loggerheads with state officials over prescription drug policies.

More than 200,000 seniors in Maine became eligible for the new Medicare Part D prescription drug benefit on Sunday, Jan. 1.

Miller said Wednesday that nearly all of the 250 Medicare prescriptions filled at his store on Sunday failed to clear the payment system. By Wednesday, almost half were still not processing as they should.

The problems stem almost entirely from computer errors, according to Miller. Many customers think, or even have documentation, that they’re enrolled in a particular drug insurance plan, only to have the insurance company’s billing computer refuse to pay for their medication. Sometimes he said, the computer simply doesn’t recognize the customer as being enrolled and rejects the claim outright. In other cases, customers who should be getting their medications for a co-pay of $1 to $3 are being asked to pay close to the full retail price because the federal Medicare computers aren’t functioning properly.

Efforts to contact the private insurance companies to work out problems have been stymied by the high volume of calls being placed nationwide and the fact that many insurers are headquartered in different time zones, he said.

Miller said most of the people encountering difficulties are “dual-eligibles” – low-income seniors who qualify for both Medicaid and Medicare but who now have to switch their drug coverage from Medicaid to the more complicated Medicare plan. Others affected include elderly people enrolled in the state’s plan called Low Cost Drugs for the Elderly and Disabled, commonly known as DEL.

An estimated 45,000 dual-eligibles and 12,000 DEL seniors were automatically enrolled in one of the dozens of private insurance plans that provide the Medicare Part D drug coverage in Maine. State officials assigned DEL members to plans that would provide the best coverage for their individual needs, and dual-eligibles were randomly assigned to plans by the federal Medicare office.

State officials recently reassigned about a third of Maine’s dual-eligibles into different plans that would provide better coverage than the ones selected at random. The state filed the bulk of its enrollment information with the Centers for Medicare and Medicaid Services, or CMS, on Dec. 20, with follow-up filings on the 22nd and the 29th, according to Jude Walsh of the Governor’s Office of Health Policy and Finance.

A suggestion by CMS officials earlier this week that Maine made matters worse for itself by switching its dual-eligibles into new plans doesn’t hold water with Walsh, who said Wednesday that most of the information was filed well before the federal Dec. 30 deadline and should have been processed in time for the Jan. 1 rollout.

Sounding frayed and frustrated from her desk at the state’s Medicare Part D enrollment hot line phone bank, Walsh said workers have been fielding about 16,000 calls each day this week from consumers and family members who are having trouble getting their medications. Many of the calls, she said, are “heartbreaking.”

“People are just beside themselves because they can’t get the drugs they need,” she said. “I’m sure there are some people getting their medicines just fine, but they’re not calling me to tell me about it.”

A separate state hot line for pharmacists has taken about 1,000 calls a day, she said, and she has participated in conference calls twice this week with about 30 pharmacists to provide guidance and support in serving their customers.

Walsh said the state has assured pharmacists and consumers that the state will not let its low-income elderly residents go without their medicines. Until the computer problems and other complications are resolved, she said, the state’s Medicaid program will cover the cost of medications as a last resort.

“We’ve been assured by CMS that they’ll help us reconcile and make good at the end of this month,” she said.

Brian Cresta, director of the regional CMS office in Boston, reiterated on Wednesday that Maine’s troubles with the Part D debut seem to have been made worse by the re-enrollment of some 15,000 dual-eligibles and the relatively late filing of DEL enrollment information. All states are reporting a bumpy first week, he said, but “it seems to be worse in Maine.”

CMS staff members are working closely with state officials to help resolve problems, he added.

Cresta predicted that matters should improve quickly as CMS computers catch up with late filings and resolve some internal glitches.

“The vast majority of Medicare Part D enrollees have walked into a pharmacy this week and gotten their drugs,” he said. “For many of these people, it’s the first time they’ve had any coverage at all.”

In Bangor, pharmacist Miller urged those less fortunate to be patient while drugstores, state officials, CMS and private insurance companies work to untangle the mess.

“People need to give us time to iron out the problems,” he said. “We all want to help people and make sure they don’t go without their medicine.”

The state’s Pharmacy Helpline for consumers can be reached toll-free at (866) RxMaine or (866) 796-2463.


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