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Cantwell Fights to Get Seniors the Medications and Care They Need

Location: Washington, DC

Cantwell Fights to Get Seniors the Medications and Care They Need

Legislation would eliminate coverage gaps, relieve burden placed on pharmacies, help seniors get life-saving drugs

Friday, U.S. Senator Maria Cantwell (D-WA) joined Senator John Rockefeller (D-WV) to introduce legislation to eliminate gaps in prescription drug coverage and get life-saving medications to low-income and disabled seniors struggling under the new Medicare drug program. The "Requiring Emergency Pharmaceutical Access for Individual Relief (REPAIR) Act" reduces the burden currently placed on pharmacies, helps them clearly identify Medicare beneficiaries, adds protections for low income seniors, and guarantees seniors access to a 30-day transitional supply of prescription drugs.

"Instead of helping seniors, the Medicare drug program has made things far more difficult," said Cantwell. "Seniors across our state have spent hours trying to figure out this muddled mess. Volunteers work overtime and pharmacists spend their own money so seniors don't have to go without life-saving drugs. This bill will put in place commonsense fixes to get seniors the medication they need and the care they were promised.

Seniors eligible for both Medicare and Medicaid are often those with chronic illnesses and the lowest incomes. These "dual eligibles" were automatically assigned to drug plans based on zip code, with no regard for which plan would actually fit them best. Dual eligibles who decide to switch plans are not covered by the new plan until the first day of the following month, leaving many without access to medications for up to 30 days. In many cases, dual eligibles have encountered higher premiums and problems changing plans, leaving them without necessary medicine for even longer. Pharmacies have had difficulties accessing necessary information from Centers for Medicare and Medicaid (CMS) and have often covered the cost of giving seniors needed medications themselves.

The REPAIR Act, introduced Friday and co-sponsored by Cantwell, would require plans to give seniors a 30-day transitional supply of the prescription drugs they were taking prior to their enrollment in a particular plan. It would also require CMS to better identify dual eligibles, bar states from conditioning Medicaid eligibility for dual eligibles on enrollment in a Medicare drug plan, and assume eligibility for seniors with proper documentation when pharmacists cannot verify dual-eligibility through CMS.

To guarantee access to prescription drugs, the REPAIR Act would:

+ Require plans to include in their transition policies a 30-day supply of prescription drugs beneficiaries were taking prior to their enrollment in their new plan. This policy applies would apply to new Medicare enrollees as well as to beneficiaries who switch plans.

+ Assume eligibility for dual eligibles at the point-of-sale who present a government-issued picture identification card, their Medicaid card, and reliable evidence of Medicare enrollment. Presumptive eligibility would apply when pharmacists cannot verify dual-eligible status through the E-1 billing system or the point-of-sale plan. Pharmacists can then bill CMS directly for these prescriptions.

+ Require CMS to clearly identify dual eligibles and share the information with prescription drug plans and ensure that pharmacists have access to the information during E-1 queries and point-of-sale encounters.

To protect low-income Medicare beneficiaries, the REPAIR Act would:

+ Prohibit states from conditioning Medicaid eligibility on enrollment in Medicare Part D for individuals who have other forms of insurance count as credible coverage under Medicare Part D, including employer-sponsored retiree coverage and Veterans health benefits.

To improve CMS customer service, the REPAIR Act would:

+ Require CMS to station one trained employee at every State Health Insurance Program (SHIP) through the open-enrollment period to help beneficiaries and SHIP counselors better understand the Medicare drug benefit.

+ Require CMS to hire additional trained professionals to reduce 1-800-MEDICARE wait times.

To reduce the burden placed on pharmacies, the REPAIR Act would: + Require CMS to provide additional outreach and education to pharmacies unaware of the E-1 billing system and how to use it, particularly independent pharmacies in rural parts of the country.

+ Reimburse pharmacies for any transaction fees related to the point-of-sale enrollment process and technology or software upgrades necessary to make identification and enrollment inquires. + Allow pharmacies to bill CMS directly for the costs of providing a transitional supply of prescription drugs to dual eligibles. Pharmacies will be able to bill CMS directly for the costs associated with providing a transitional supply of prescription drugs to dual eligibles presumed eligible based on the standards listed above and for which pharmacies are unable to get verification of status from the E-1 billing system or point-of-sale plan.

To provide federal reimbursement to states and beneficiaries, the REPAIR Act would:

+ Require CMS to compensate to dual eligibles incorrectly charged premiums, deductibles, or other cost-sharing. Dual eligibles incorrectly charges premiums or deductibles. Beneficiaries will receive refunds directly, either through a direct payment or a rebate on future Social Security checks.

+ Requires CMS to provide full reimbursement to states incurring unexpected costs filling the gaps in the Medicare drug program in 2006.

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