aring for our Elders: the Transition to Medicare-D
Introduction
The Medicare Prescription Drug program has been a mainstay topic in the press over last year. It is, of course, much more than a political controversy or fodder for editorials. The issues surrounding Medicare-D touch the lives of nearly every American, including the frail, elderly population at the center of Hearth's work.
The creation of the Medicare-D Program and its subsequent enactment on January 1, 2006 was a major event for Hearth. Staff began preparing for the enactment nearly a year in advance, attending meetings, in-services, and participating in nation-wide conference calls. Within Hearth, May Shields, Director of Health Services, along with all of the nurses, social workers, and site directors needed to create an action plan to transition the affected residents as smoothly as possible.
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Nurses are important to Hearth's work. From left to right: May Shields, COO; Ethel Foweks, Director of Health Servcies; Ellen Nolan Gard, former COO and current Board of Vistiors member. |
Table of Contents
Profile: Hearth's Clientele
The average Hearth resident is approximately 62 years old and has a complex medical history involving multiple chronic illnesses and a regimen of six prescription medications. Finding the right prescription drug plan for each resident among the numerous choices - there are 45 plans offered in Massachusetts - was a daunting challenge. The new system helped reduce the size of the pool of plans because the vast majority of Hearth’s elders - at least 90% - are "dual-eligible."
The term "dual-eligible" means an individual who, because of his/her low-income, qualifies for both Medicare and Medicaid. In Massachusetts, previous to the creation of Medicare-D, dual-eligible elders were enrolled in MassHealth, a program which covered their prescription costs and required pharmacies to give out medications even if that individual could not afford the low co-pay. Under Medicare-D dual-eligible elders were automatically assigned (but not officially enrolled) into a new drug plan. The monthly premiums are paid by the government. In Massachusetts, there are currently twelve plans available to dual-eligible individuals. Thus, Hearth staff only had to compare those twelve plans (not all forty-five) to find the best option for each resident.
Ms. Shields reported that fortunately between 40% and 60% of Hearth’s elders were auto-assigned to a plan that covered all of their medications and no changes needed to be made for them. On January 1, those residents were officially switched from MassHealth to Medicare with only minor inconveniences. However, finding the correct plan for our remaining elders was quite a challenge.
Navigating the System
Finding the right plan for residents was a time-consuming, multi-step process, and Ms. Shields was often quite astonished by the results. "I was shocked at what some of the plans didn't cover. Commonly prescribed medications were not included in some of the plans. The program's comparison tool on the Medicare website is useful," said Ms. Shields. "The tool is fairly simple to use, but basic computer knowledge is necessary. Very few of our elders would be able to use it without help. I also feel that basic knowledge about medication is useful, knowing the exact name and type of each prescription medicine." In addition, while the tool can compare three plans at a time, only two plans can be compared in the print-out.
However Ms. Shields says she was pleasantly surprised at how easy it was to change plans once a better plan was identified. There are problems, however, in communicating such change. It can take weeks for the plan's provider to communicate changes to Medicare, Social Security, and the pharmacy. And unlike MassHealth, pharmacies are not required to supply prescriptions to individuals whose information is not in order, or who cannot pay the co-payment.
Currently, thanks to the hard work of the staff, all of Hearth’s eligible residents have been enrolled into a plan. However, Ms. Shields is cautious about celebrating. If a resident is prescribed a new medication not covered under the current plan, the process of choosing a new drug plan has to start all over. According to Ms. Shields plan providers can eliminate medications or change drug tiers at any time during the year with sixty days notice. This could result in residents requiring medications that are not covered by their plan. Although an extensive appeals process is in place, Ms. Shields feels that few elders would be able to navigate that complicated process on their own. "If it were me," she admitted, "I probably wouldn't pursue my appeal past the first rejection. It's just too complicated and time-consuming."
For the time being, all of the residents have been taken care of, and Hearth’s President and CEO, Elisabeth Babcock, is impressed by the staff’s hard work, dedication, and achievement.
SCO: Senior Care Options
Hearth is also participating in a program called SCO: Senior Care Options. SCO is a partnership of the federal Centers for Medicare and Medicaid Services and the Commonwealth of Massachusetts. The program is a holistic approach to providing care for seniors, combining health-care services with social support services and matches well with Hearth's philosophy of caring for the entire person. SCO covers all the health services of MassHealth and Medicare and also, with the input of the elder, creates an individualized service plan with the goal of keeping him/her as independent as possible. The program gives elders the option to remain at home with needed care and supports rather than going to a hospital or nursing home.
Ms. Shields believes that joining a SCO program will be the right choice for many Hearth residents. Currently, about ten residents are enrolled in SCO through the Commonwealth Care Alliance and Evercare Senior Care Options. If all goes well, more residents will be enrolled into the program. Through contract arrangements each SCO pays Hearth to provide services to those enrolled.
Hearth's mission to provide frail elders with caring homes works with a combination of affordable housing and supportive services. Hearth's staff showed their excellence and dedication to this mission during the complicated transition to Medicare-D. In addition, by participating in programs like SCO, Hearth continues its efforts to bring needy seniors home for good.
Resources
Unfortunately, Hearth staff did not discover a magical formula that made Medicare-D easier to decipher. Primarily, finding the correct drug just takes time and patience. Below are some online resources that you may find helpful.
The Official Medicare Website: http://www.medicare.gov/pdphome.asp
The official government Medicare website gives you access to all
Medicare-D related publications and information distributed by
Medicare. The website also contains two different comparison
tools to help you choose the correct plan. The first tool, Medicare
Prescription Drug Plan Finder (http://www.medicare.gov/mpdpf/home.asp),
compares plans according to your cost and coverage needs. The
second tool, The Formulary Finder (http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp),
compares plans according to specific prescription coverage.
Medicare offers live, in-person help 24 hours a day via their helpline at 1-800-MEDICARE. Your doctor and your pharmacist can also be good sources of help and information.
The Kaiser Family Foundation: http://www.kff.org
The Kaiser Family Foundation is a non-profit foundation that focuses
on the major healthcare issues facing the nation, including Medicare
(http://www.kff.org/medicare/index.cfm).
They offer a wealth of information, including the latest studies on
the efficacy of Medicare-D and a current analysis of the healthcare
coverage of each state.
The Center of Medicare Advocacy, Inc.: http://www.medicareadvocacy.org
The mission of the Center for Medicare Advocacy (CMA) is to
"increase access to comprehensive Medicare overage and excellent
health care for elders and people with disabilities by providing the
highest quality analysis, education and advocacy."
We hope you found this article interesting and helpful. Please let us know what you think. Email Hearth with your questions or comments. Thank you!