Hoping for the best, but preparing for the worst, mental health advocates
are bracing for the start of Medicare's new Part D prescription drug benefit
in January like islanders awaiting a momentous change in the weather with only
vague forecasts—it could be really good, or it could be really, really
When the new program begins January 1, 2006, some 40 million Medicare
beneficiaries, including "dual eligibles" who receive both
Medicare and Medicaid benefits—as many as 2.5 million of whom have
mental illness—will be eligible for prescription drug coverage.
A component of the Medicare Modernization Act of 2003, the new program is
hailed by the Bush administration as an historic opportunity for millions of
Americans to receive government-subsidized coverage of prescription drugs. A
report by the Medicare Today coalition found that the amount of money
low-income seniors spend on prescription drugs will fall nearly 90 percent
under the new program. The approximately 8 million beneficiaries who earn 150
percent of the federal poverty level or less—approximately $14,500
annually—will see their out-of-pocket costs for prescription medications
drop from $1,657 to $180 a year, according to the analysis.
Medicare Today is a broad-based partnership of organizations representing
seniors, patients, health care groups, employers, and others.
So much for the good news.
APA has taken the lead in preparing for—and trying to head
off—countless worstcase scenarios and potential problems in the new
program identified by mental health advocacy groups. In collaboration with the
National Alliance for the Mentally Ill and the National Mental Health
Association, APA is sponsoring a Web site at<www.mentalhealthpartd.org>
intended to be an all-purpose site for resources related to the Part D program
for psychiatrists, mental health professionals, and the public.
Among the most prominent concerns with the new program are communicating
with and educating beneficiaries who may be only vaguely aware of the
existence of the program, never mind its specific benefits; potential problems
with plan enrollment; possible formulary exclusions and restrictions;
continuity of care issues; and issues with premium payments and deductibles
that may be severe financial hardships for the poorest and most severely ill
Also of great uncertainty is the status of medications used to treat
substance abuse (see story at bottom of facing page).
Moreover, Part D is unusually complex—even by Washington bureaucratic
standards—in part because of the complicated financing mechanisms by
which the entire act was made to come in under the budget expectations of the
Republican majority who approved it.
For instance, imbedded in the formula for financing the program is a
provision requiring states to pay a portion of the costs they will no longer
incur for drug coverage under their Medicaid programs—the so-called"
clawback formula," an unintended consequence of which could be to
cause states to drop patients from their Medicaid rolls (see story at top of
The focus of APA and other advocates has been most keenly on that special
category of beneficiaries who qualify for both Medicare and Medicaid by virtue
of age and/or poverty and disability, many of whom have mental illness. Their
drug coverage under the Medicaid program will cease on January 1, 2006, when
the new Medicare Part D program begins.
Mental health advocates say the new benefit could prove tricky to navigate
for a population that may be cognitively impaired or may not read its mail.
Many are predicting a rocky transition from a Medicaid program that had been
providing reasonable access to prescription drugs, including psychiatric
medications, to a new program in which the drug plan formularies are unknown
at press time.
APA has been active in negotiating with the federal Centers for Medicare
and Medicaid Services (CMS) to ensure that psychiatric drugs are included in
the formularies of the prescription drug plans (PDPs). Marketing of those
plans begins this month.
"We are talking about moving people from 50 state programs, which for
the most part have had relatively unrestricted access to psychiatric drugs, to
a new program in which we don't yet know what the formularies will look
like," said Irvin Muszynski, J.D., director of APA's Office of
Healthcare Systems and Financing. "We know for certain that for the dual
eligibles it's going to be a major change. Whether it's good or bad depends on
a number of things that we don't know yet. Most important is what the final
prescription drug formularies will actually look like with regard to the
relevant psychiatric medications and what kind of access restrictions may
"Cautiously optimistic" is how Jennifer Bright, senior vice
president of state policy for the National Mental Health Association,
characterized expectations about the new program. "For dual eligibles,
it's a question mark because we don't know what the plans look like. CMS has
told us that all our concerns are going to be met, but we won't know that
until the middle of October.
"At that point, we will essentially have six to eight weeks to
evaluate how good the plans are and communicate it to a couple of million
people," Bright told Psychiatric News. "It's a waiting
By statute, benzodiazepines will not be on drug plan formularies, though
Bright noted that legislation has been introduced in Congress to include that
class of drugs (Psychiatric News, August 5).
Marc Steinberg of Families USA said that many state Medicaid plans have
opted to provide benzodiazepine coverage. "They can continue to cover
them if they wish to, and in fact CMS is urging states to continue to cover
these drugs," Steinberg told Psychiatric News. "After
January 1, dual eligibles could then have two sources of drug
coverage—Part D for most medications and Medicaid as secondary coverage
for nonPart D drugs, like benzodiazepines.
"Not so easy for anyone to understand, especially someone with mental
illness, but workable in theory," Steinberg said.
Yet it is just such convolutions that seem to characterize many aspects of
the new program, especially for the dual eligibles. Following are just a few
of the most crucial issues and potential problems for both the dual eligibles
and the regular Medicare beneficiaries that APA and other mental health
advocates are following:
"These are higher than in most states in Medicaid now," said
Families USA's Steinberg. "Plus these copays are indexed to inflation,
so they will increase over time. This could be a real hardship for
Muszynski remarked that many of the most troubling glitches in the
transition to the new program will be, so to speak, "on the
ground"—when a cognitively impaired patient who does not routinely
open and read mail misses a vital communication about eligibility for a
low-income subsidy or enrollment in a plan that may or may not cover the
"My greatest concern is that even if the formularies are perfect,
it's the little logistical things that could go wrong," he said. He
cited the example of a patient who does not have the cash to make a copayment
at the point of sale. "What happens to the patient then?" he
asked. "Is he just told to go away?
"Ultimately, the Part D program is essentially a capitated model to
pay for drugs," Muszynski said. "That may work actuarially, but we
are dealing with populations that have chronic and enduring illness. They
don't fit the average, and the program creates incentives to stint on
Medicare Today's report, "Medicare Tomorrow: Future Savings
for Beneficiaries," can be accessed at<www.medicaretoday.org/index.php?src=gendocs&link=toolbox>.▪