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Medicare Part D: a guide for long-term care providers.

The concept is simple: Our country's elderly and disabled citizens need prescription drug coverage. After much debate about the specifics, Congress created a prescription drug benefit for Medicare beneficiaries--"Part D"--that begins on January 1, 2006 (Congress also created temporary Medicare discount drug cards and subsidies that will be phased out as Part D goes into effect). But the benefit is no simple matter, and the details can be daunting.


Beginning next year, Medicare beneficiaries will be able to access prescription drug coverage through private prescription drug plans (PDPs) (for an overview of all the parts of Medicare, including Part D, see the table, page 71). Some beneficiaries will be choosing from among these plans for their drug coverage, while others might continue on their current plans (such as employer-sponsored plans). And those beneficiaries considered "dual eligibles" (that is, eligible for both Medicare and Medicaid benefits) will have their drug coverage switched from Medicaid to Medicare.

The new Medicare drug coverage will rely on restrictive formularies as a cost-containment measure, although the federal government has promised substantial access to antidepressants, antipsychotics, anticonvulsants, HIV/AIDS drugs, cancer medications, and immunosuppressants (all of which could be subject to utilization controls, such as prior-authorization and step therapy mandates). Medicare will not cover some drugs important to long-term care residents, such as barbiturates and benzodiazepines. Individual states will decide whether to cover these drugs' costs through their Medicaid programs, although as of press time federal legislation was pending to have Medicare cover benzodiazepines' costs.

Starting November 15, many Medicare beneficiaries (such as those in assisted living facilities) will choose their PDP, weighing formulary restrictions against cost-sharing measures and other factors when making this complex decision. According to sources at press time, the dual eligibles, who constitute a large portion of nursing homes' resident populations, will be automatically enrolled in a PDP if they do not choose one themselves.

The new benefit has many nuances for all would-be beneficiaries to consider, including a so-called "doughnut hole"--a gap in coverage during which beneficiaries continue to pay premiums but also pay all of their drug costs until "catastrophic" expense levels are reached. The doughnut hole will apply to Medicare-only beneficiaries (such as many assisted living residents and short-stay nursing home patients), but it will not apply to dual eligibles (who constitute a larger proportion of nursing home residents).

Long-term care providers face many challenges, including answering residents' and families' questions, dealing with multiple formularies with idiosyncratic restrictions, enhancing relationships with long-term care pharmacy companies, and ensuring continuity of care when the benefit goes into effect. To offer some assistance to long-term care providers trying to understand Part D's complexities, this special section to Nursing Homes/Long Term Care Management features thought leaders' perspectives on the benefits, challenges, and questions involved. A resident and family handout with information about Medicare Part D also is included (page 72); providers are invited to photocopy and distribute it to residents and their families.

We remind readers that the information in this special section is current as of press time, when several details of the new benefit still hadn't been finalized.

Preparing for a Gazillion Issues

As of mid- to late summer, just how many issues still need to be worked out about Medicare Part D? Barbara Manard, vice-president of long-term healthcare strategies at the American Association of Homes and Services for the Aging (AAHSA), suspects it's "a gazillion." Humor aside, Manard admits that a bumpy road lies ahead for the transition of dual eligibles' drug coverage from Medicaid to Medicare. She says developing processes to meet the challenges posed by Part D will be key to successfully implementing the new prescription drug benefit.


One such challenge is as basic as how nursing homes will find out in which prescription drug plans (PDPs) their residents are enrolled. Manard says electronic systems are being developed to provide facilities with this information, but they probably won't be ready by the January 1 start date. Thus, in the meantime, facilities will have to ask residents and families for their PDP information or consult with long-term care pharmacies. She says this is not a legal issue, but rather a technologic one, and there just hasn't been enough time to develop the necessary systems.

Another challenge Manard points to is working with PDPs' restrictive formularies. "Because we really haven't had formularies to a great extent in nursing homes before, it will require developing new technologic systems of communication to make it work," she says, noting that such systems would allow caregivers to look up a PDP's formulary, along with its restrictions. Again, she says it will take time to develop the necessary technology to allow for this.

Residents and their families certainly will have many questions about PDPs and formularies. "The details of how to make a choice about this program are really mind-boggling when you get into the nitty-gritty of it," admits Manard. To help out, she says facilities can display educational posters and bring in speakers, although they are not supposed to make PDP coverage decisions for residents. Manard explains that a staff member can make such decisions only in the rare instance in which that person is the resident's guardian under state law. The Centers for Medicare & Medicaid Services (CMS) has issued draft guidance outlining what providers, such as pharmacies and long-term care facilities, can and cannot do with regard to helping beneficiaries make choices under Part D. Manard says that while providers are encouraged to make unbiased information available, they are not to steer beneficiaries toward one or a limited number of PDPs (for more information, see page 50 and the following pages at

To obtain educational materials and arrange for speakers at educational events, Manard suggests providers contact their state health insurance assistance program (SHIP), which provides information, counseling, and assistance to Medicare beneficiaries and their caregivers (for specific contact information, see, Medicaid program (, or state or area agency on aging ( Families should be invited to these events, too.

Manard does not see any particular issues for not-for-profit facilities preparing for Medicare Part D. She does have some concerns, however, about dually eligible residents of assisted living facilities. Congress decided that dually eligible beneficiaries of "long-term care institutions" are not subject to copays for their drugs under Part D. CMS decided that "long-term care institutions" means nursing homes and does not include assisted living facilities. Manard says that this poses a financial dilemma for assisted living residents receiving Medicaid assistance (granted, the number of assisted living residents receiving Medicaid assistance is small, but Manard says about 40 states have Medicaid-reimbursed programs for assisted living). Although the copays for dual eligibles are modest--$3 to $5--Manard says they could take a significant bite out of the $30 to $40 personal needs allowance that Medicaid beneficiaries tap to pay for deodorant, toothpaste, and even grandchildren's birthday presents. Therefore, AAHSA would like to see CMS alter its definition of "long-term care institutions" to include assisted living so that dually eligible assisted living residents are not subject to prescription drug copays.

With so many issues to consider--perhaps fewer than a gazillion, but enough--administrators and operators will certainly have their hands full as they prepare for Medicare Part D. Manard would like to remind them that the provider associations are working overtime to help them, and to stay tuned to AAHSA's Web site ( for the latest information.

The Consultant Pharmacist's Perspective

Now might be the time to consider a career as a consultant pharmacist. With all of Medicare Part D's requirements and stipulations, it's no surprise that Thomas R. Clark, RPh, MHS, director of policy and advocacy at the American Society of Consultant Pharmacists (ASCP), expects to see opportunities grow for consultant pharmacists in the years ahead. For those nursing home professionals satisfied with their current jobs, Clark suggests some of the challenges they will face as they prepare for the new Medicare prescription drug benefit.


First on the list is the time crunch: By January 1, 2006, eligible beneficiaries will need to be signed up in a prescription drug plan (PDP). Then there's the question of how much of a role a facility can have in helping residents sign up for Part D. The Centers for Medicare & Medicaid Services (CMS) says facilities should not steer residents toward a particular plan. But Clark says, "I think you're going to see some facilities at least doing that to some extent, because there are bound to be some PDPs that just do not match very well with long-term care settings" because of issues such as tiering of medications in a formulary. To make sure new residents have designated a PDP or will do so when they are eligible to choose one, Clark says facilities might discuss this topic with residents and families during the admissions process.

Facilities will certainly be challenged by having residents using different PDPs, each with its own formulary restrictions. Although Clark is pleased that CMS has directed PDPs to offer substantial access to antidepressants, antipsychotics, anticonvulsants, HIV/AIDS drugs, cancer medications, and immunosuppressants, he's concerned that PDPs are not required to cover all these drugs' dosage strengths and extended-release forms that can be of particular value in long-term care settings. ASCP is working with CMS to address this issue.

Some drugs used by long-term care residents, such as benzodiazepines and barbiturates, will not be covered by Medicare. It will be up to individual states' Medicaid programs to determine whether to cover drugs not covered by Medicare. ASCP is working with other stakeholders to urge Congress to pass recently introduced legislation to require Medicare to cover the benzodiazepines.

Long-term care pharmacies will have a vital role under Medicare Part D. CMS has recognized long-term care pharmacies as a separate category of pharmacy, and PDPs are required to have separate long-term care pharmacy networks, instead of lumping long-term care pharmacies into retail networks, says Clark. This is a new relationship for both players involved: "Pharmacy benefit management companies and managed care companies in the past have had no relationship with long-term care pharmacies or long-term care settings. They just didn't understand long-term care," says Clark, pointing out that the original contracts PDPs sent to long-term care pharmacies were more appropriate for retail pharmacies. He notes that long-term care pharmacies have been working with PDPs to educate them about long-term care issues.


Long-term care pharmacies will serve as the connection between PDPs and nursing homes. Although there won't be a formal relationship between the PDP and the facility, the long-term care pharmacy will serve as the go-between, contracting with the PDP and also contracting with the facility. For those facilities (freestanding or hospital-based) served by outside long-term care pharmacies, Clark has the following advice in preparing for Medicare Part D:

* Educate facility staff about Medicare Part D. With the help of the quality assurance committee, make sure the director of nursing, medical director, administrator, and consultant pharmacist know the details of the new Medicare prescription drug benefit.

* Develop an action plan for preparing for implementation of Part D.

* Find out what PDP region your facility is in (see regions), as well as the PDPs available in your region (this information should be available in mid-September). Keep in mind that not all plans will be available to dual eligibles.

* Review each plan's formulary, utilization controls (e.g., prior-authorization requirements, step therapy mandates, etc.), and exceptions process (for a basic overview of the Medicare exceptions, appeals, and grievance process, see the figure, but note that PDPs might use different forms to initiate the process). The long-term care pharmacy can be especially helpful with evaluating this information, and facilities might find it helpful to contract with a pharmacy that has a relationship with many PDPs.

* Determine which plans your residents have enrolled in/been assigned to. Facilities will not be provided with this information. Residents or their families will have to notify facilities of their plan, or facilities can work with their long-term care pharmacy to determine individual residents' PDPs. ASCP is working with CMS on the logistics of this process.

* Make sure all eligible residents are signed up for a PDP by the end of the year.

Hospital-based skilled nursing facilities served by a hospital's pharmacy will face a complicated set of special issues. Clark says ASCP is preparing guidance on this topic that will be available on its Web site,

Clearly, consultant pharmacists will be an important resource for facility staff as they prepare for Part D, so now would be a good time for facilities to strengthen their relationships with long-term care pharmacies, advises Clark: "Facilities should begin to address learning about Part D as much as they can, working with long-term care pharmacies to try to prepare so they're ready to go on January 1."

Priority Number One: Residents

Amid the regulations, formularies, and guidance documents on Medicare Part D, it's probably easy to lose sight of residents' perspective. For that reason, certified geriatric pharmacist Jeannine Powell, PhD, believes that taking time to address residents' fears and concerns is just as important as preparing to work with multiple prescription drug plans (PDPs) and restrictive formularies.

"A lot of seniors and their family caregivers are going to be concerned and need some reassurances," says Dr. Powell, who is director of pharmacy at long-term care company Beverly Healthcare. "I think probably the most important message is that while the Medicare Part D program is going to change the way residents' drugs are paid for, everybody involved--including the Centers for Medicare & Medicaid Services [CMS], states, PDP sponsors, long-term care pharmacies, and certainly nursing facilities--is really committed to making sure they get the medications they need for their care and treatment."

Frontline staff certainly will have their own questions about Medicare Part D and how it will affect their daily work. Dr. Powell says Beverly is waiting to widely disseminate materials to these staffers until after the PDPs are formally announced (by September) to ensure they receive accurate, consistent, and up-to-date information; until then, many questions on the program's specifics will remain unanswered. In the meantime, Beverly is encouraging its facilities to engage medical directors and attending physicians to ensure they have sound communication structures and working relationships in place.

Based on the information currently available, Beverly does have concerns as the implementation date nears. One example: Beverly is committed to ensuring that residents newly admitted to long-term care environments from hospitals (which have their own formularies) have immediate access to their medications. Dr. Powell says CMS has recognized this problem and has directed PDPs to cover new residents' current medications during a transition period, giving physicians and residents time to evaluate their options. "CMS has really expressed a willingness to work with the PDPs and the providers to resolve these issues," she notes.

Dealing with such issues is going to take changes in operational structures, which Beverly plans to pursue aggressively once the PDPs are formally announced. "We'll know more when the PDPs are officially approved and we can talk directly to them and see what their processes look like," Dr. Powell explains. Implementing Part D certainly will take hard work and perhaps difficult changes, but Dr. Powell says that it's the residents' needs that will be the priority at Beverly: "In the long run, whatever the resident needs, the resident is going to get. We'll just have to figure out how to make that happen."

The Changing Relationship With States

The nature of the relationship between state Medicaid agencies and nursing homes is about to change. The new Medicare prescription drug benefit will make Medicaid less of a player in many nursing home residents' prescription drug coverage, but that doesn't mean state Medicaid agencies are sitting on the sidelines during the transition.

Cliff Binder, a senior health policy associate at the American Public Human Services Association (of which the National Association of State Medicaid Directors is an affiliate), says states are working on outreach to providers, physicians, pharmacists, and beneficiaries. Regarding the latter, Binder says the Centers for Medicare & Medicaid Services (CMS) and states have been developing a computerized process for identifying dual eligibles, who make up a large portion of nursing homes' resident populations. Although some dual eligibles might be missed in the auto-enrollment process, Binder says CMS and the states are creating fallback programs for handling dual eligibles who find themselves not enrolled in a prescription drug plan after January 1.

A big question surrounding states' role under Part D is whether they will cover drugs Medicare will not pay for. These include drugs important for many long-term care residents, such as barbiturates and benzodiazepines. Binder thinks many states will elect to cover these drugs (and, as of press time, federal legislation was pending to have Medicare cover benzodiazepines).

Binder suggests that long-term care professionals can refer residents and families who have questions about Medicare Part D to states' consumer health assistance programs (for state-specific information, see the Program Locator at, state pharmaceutical assistance programs (see, and state health insurance assistance programs (SHIPs) (see

Peering Into the Medicare Part D 'Doughnut Hole'

Many people enjoy dunking their doughnuts in coffee, and Medicare beneficiaries might need more than a few cups when taking in Part D's "doughnut hole." Judith Stein, JD, executive director and founder of the Center for MedicareAdvocacy, Inc., explains that this doughnut hole is essentially a second deductible that beneficiaries pay under Part D drug coverage. The doughnut hole applies to Medicare-only beneficiaries, such as many assisted living and short-stay nursing home residents. It does not apply to dual eligibles, who constitute a larger proportion of nursing home residents. It was designed as a cost-containment measure.


Here's how Stein says it works: The individual pays a monthly premium averaging $37 per month. After an initial $250 deductible, the patient pays 25% and Medicare pays 75% for the next $2,000 worth of drugs on the plan's formulary. Once the person reaches the $2,250 threshold (of which Medicare has paid $1,500 and the beneficiary has paid $750), the individual reaches a second deductible--the doughnut hole--during which time the person pays $2,850 out of pocket for covered drugs before Medicare Part D coverage resumes. Once a beneficiary reaches the far end of the doughnut hole, he will pay either 5% of the cost of a covered drug, or $2 per generic drug and $5 per brand-name drug, whichever is greater, for the rest of the year. Premiums, deductibles, and the doughnut hole will be "indexed," meaning they could increase each year.

Stein points out that beneficiaries will still pay their premiums while in the doughnut-hole stage. In fact, she points out that the Kaiser Family Foundation estimates that 24% of Medicare Part D participants will fall into the doughnut hole, and only 11% of Medicare Part D recipients will emerge from it to qualify for catastrophic coverage. The Medicare Part D payment system recommences each year.

For more information, see



RELATED ARTICLE: Long-Term Care Residents and the Medicare Prescription Drug Benefit

Important factors for residents and their families to keep in mind

** Your facility's caregivers can give you information about the new Medicare prescription drug benefit, but they cannot choose a plan for you (except in rare cases).

** If you are eligible for both Medicare and Medicaid (that is, considered "dually eligible"), you will be automatically enrolled in a prescription drug plan if you do not choose one yourself. Many nursing home residents are dually eligible.

** If you are eligible only for Medicare, you must choose a drug plan to receive prescription drug coverage under Medicare. Many assisted living residents and short-stay nursing home patients are eligible only for Medicare.

** Each Medicare prescription drug plan will use a formulary, a list of drugs the plan will pay for. It is important to compare plans and see if their formularies cover the drugs you take.

** If you are eligible to enroll in a Medicare prescription drug plan but choose not to during the designated enrollment period, you might have to pay a higher premium if you enroll later on. If you currently have prescription drug coverage that is "creditable"--that is, equal to or better than the Medicare drug benefit--and choose not to enroll now, you will not have to pay a higher premium if you enroll in a Medicare drug plan later on. Check with your drug plan or your employer's human resources department to determine if your current prescription drug plan is creditable. VA drug coverage is considered creditable.

** If you are dually eligible for both Medicare and Medicaid, you can change your prescription drug plan at any time. If you are eligible only for Medicare, you can change your plan only during the designated annual enrollment period (check with your prescription drug plan for more information).

** If you are dually eligible and are living in a nursing home, you will not have copays for prescription drugs.

** Even if you are not eligible for Medicaid, you may be eligible for assistance in paying for the costs of your prescription drugs. If you are someone with limited income and resources, visit the Web site to find out if you will qualify for extra help from Medicare in 2006 or from other existing benefits programs.

** Many Web sites have helpful resources on the new Medicare benefit. One example is UnitedHealth Group's Medicare Rx InfoSource Web site ( On the site is a downloadable, 24-page "Show-Me Guide" about the new Medicare drug benefit.

** If you need help understanding the new Medicare prescription drug benefit and the choices involved, contact your state health insurance assistance program. If you don't know how to reach your state's program, call 1-800-MEDICARE for the contact information.

Please feel free to photocopy and distribute this page.

Sources: Center for Medicare Advocacy, Inc.; National Council on the Aging; UnitedHealth Group
Table. A quick guide to Medicare's four parts

 Part A -- "Hospital Part B -- "Medical
 Insurance" Insurance"

Year 1965 1965
Principal Inpatient hospital care, Outpatient care, 80% of
benefits post-acute care in skilled Medicare-approved cost of
 nursing facilities (SNFs), most approved equipment and
 hospice and limited home supplies, one physical exam
 healthcare services, limited within 6 months of initial
 frequency of cancer and enrollment in Part B (new in
 cholesterol screenings 2005)
Eligibility Social Security Medicare beneficiaries who
 beneficiaries who are over pay a set monthly premium
 age 65, or have specified
 disabilities or end-stage
 renal disease; some people
 who did not pay enough into
 Social Security can purchase
 Part A coverage
Mental Inpatient care, with a 50% of outpatient care, plus
health 190-day lifetime limit for a set copay for some
coverage care in mental health facility charges
 specialty hospitals
Restrictions Generally covers 90 days of No coverage for most vision
 each inpatient episode, and care, dentistry, or most
 up to 100 days of SNF care routine physical,
 following at least three gynecologic, or podiatric
 days of hospitalization; no exams; no coverage outside
 coverage outside the United the United States
Costs to 20% copay for some services; Nationwide monthly premium,
patient total deductible of $876 for plus up to 20% of
 up to 60 days of hospital Medicare-approved costs for
 stay; higher deductibles services and supplies; copay
 charged on a daily basis may be higher if doctor or
 after 60 days; daily other provider does not
 deductible for care in SNFs accept Medicare
 imposed after 20 days
Issues for Unfairly low reimbursement No coverage (although some
long-term rate for SNFs services in SNFs and
residential assisted living

 Part C -- "Medicare Part D -- "Prescription
 Advantage Plans" Drug Benefit"

Year 1997 (HMO enrollment was 2003 (not yet implemented)
established available as early as the
Principal Enrollment in a private Enrollment in a prescription
benefits plan that provides at least drug benefit plan that
 all Part A and Part B provides reduced costs for
 coverage; often includes FDA-approved prescription
 routine exams, vision care drugs and for medical
 and dentistry, wellness supplies associated with the
 services, prescription injection of insulin
 benefits (syringes, needles, alcohol
 swabs, etc.)
Eligibility Enrollees in Parts A and B Enrollees in Parts A or B
 (except those with end-stage who pay a monthly premium;
 renal disease) who pay a Medicare enrollees who also
 monthly premium; Part C receive Medicaid will be
 plans are not available in required to enroll
 all parts of the country
Mental Varies, depending on the The federal government
health plan requires substantial access
coverage to antipsychotics,
 antidepressants, and mood
 stabilizers in prescription
 drug plans' formularies
Restrictions Varies, depending on the Many medications used to
 plan; except for emergency treat seizures and mental
 care, most will not health disorders are
 reimburse providers outside excluded from coverage by
 of local area law. Excludes most vitamins
 and mineral products;
 benzodiazepines; treatments
 for hair loss, weight gain,
 anorexia, fertility, etc.;
 medications not in the
 specific plan's formulary
Costs to Premiums and fees vary, Premium charged by each plan
patient depending on the details of will vary; enrollees in the
 each plan; patient usually same plan will have varying
 pays full cost of providers copays, depending on how
 outside of local network much they spend on drugs
 annually; patient pays
 premiums during a gap in
 coverage ("doughnut hole")
 before catastrophic coverage
Issues for Typically provides no Each resident enrolled in
long-term coverage beyond that Part D may be a member of a
residential offered by Part A different drug benefit plan
care with its own formulary

Compiled by Michael J. Stoil, PhD
COPYRIGHT 2005 Vendome Group LLC
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:SPECIAL SECTION
Publication:Nursing Homes
Geographic Code:1USA
Date:Sep 1, 2005
Previous Article:Building clout on Capitol Hill: an interview with Hal Daub, president and CEO, the American Health Care Association.
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