Race is on to move millions from Medicaid to Medicare

The Centers for Medicare & Medicaid Services says it's doing all it can to move the six million people who are eligible for both Medicare and Medicaid into the Medicare drug benefit program, which starts Jan. 1, 2006. But states and provider groups say CMS' work may not be enough.

What there is consensus on is that "dual eligibles" are often at risk medically and any lapses or forced transitions to less appropriate drugs could be disastrous for individuals. "Because they are the most vulnerable of our populations, we are totally appreciative of the enormity of the task of moving them from a Medicaid program," said Leslie Norwalk, CMS deputy administrator, recently at the National Managed Health Care Congress in Washington, D.C.

The Medicare Payment Advisory Commission found last year that more than "one-third of dual eligibles are under 65, 38% have cognitive or mental impairments, 22% have multiple physical impairments, and 23% are institutionalized."

But advocates worry there may be hitches in that process. Further, as Tina Kitchin, M.D., medical director in the Oregon Department of Human Services, told the Senate Committee on Aging in early March, the random enrollment would be part of the problem: "The average Oregon dual eligible has 10 to 12 medications. It is highly unlikely that all beneficiaries will be auto-enrolled in plans where the formulary completely matches their current medication profile and their pharmacy of choice," she said.

Kitchin requested that CMS require drug plans to cover current medications at current pharmacies for at least six months, to allow agencies and others to help these beneficiaries.

On the other hand, CMS' Norwalk assured providers, "It is really critical for us to ensure that they all have coverage by Jan. 1, so we are going to do that quite early in the process."

The agency is now establishing data exchanges with the states to identify all full-benefit dual eligibles. Norwalk did note, however, the complexity of dealing with 51 different state Medicaid plans. After identifying dual eligibles, she said, CMS would contact them this summer "with all due speed," to let them know they are eligible for the benefit and for the low-income subsidy. Information will be available through http://www.medicare.gov/ the toll-free 1-(800) Medicare number, state Medicaid offices, and the Social Security Administration.

Automatic enrollment would be done long before Dec. 31, promised Norwalk, and even after that beneficiaries would have an opportunity to switch plans.

CMS is also telling states they may allow dual eligibles to get a 60- to 90-day supply of prescriptions under Medicaid toward the end of the year to ease the transition.

Norwalk pointed out that all low-income Medicare beneficiaries, including the dual eligibles, would have extensive assistance in signing up for the benefit and the low-income subsidy. CMS is working with Social Security so beneficiaries can sign up with that agency or with the states. They can sign up by mail, on-line, by phone, or in person, and no financial documentation will be required at the time they apply.

"Beneficiaries will be asked for follow-up documentation only if we can't verify what is written in the application through a data match," Norwalk noted. She also said that for the states with pharmaceutical assistance plans, there would be issues in transferring beneficiaries similar to the problems with dual eligibles. That's why CMS is working with governors, state legislators, state agencies, and others to create a very broad understanding of this.

CMS administrator Mark McClellan, M.D., Ph.D. also told the Senate committee the agency would work with providers, including pharmacies, to help them assist beneficiaries.

But Kitchin and others pointed out that these beneficiaries would need help in selecting a plan at the same time other beneficiaries need help. For those without active friends or family, it will fall to Area Agencies on Aging, Community Mental Health programs, state Medicaid offices, and other agencies with no extra funding for the counseling.