Report says auto-enrolled nursing home residents aren’t getting the best plan
An analysis released tby the Long Term Care Pharmacy Alliance (LTCPA) finds that most low-income nursing home residents have a poor chance of being enrolled in the Medicare Part D plan that best covers their medications – and most could immediately switch to a better plan at no cost if they were allowed to receive help from their caregivers. Under the Medicare Part D prescription drug program, low-income nursing home residents who are “dual eligible” for both Medicare and Medicaid are qualified to have their medicines covered at no cost as long they are enrolled in one of several drug plans recognized as “below benchmark” in cost by the federal government’s Centers for Medicare & Medicaid Services (CMS). The LTCPA analysis finds those below benchmark plans vary greatly in terms of the drugs they cover and the restrictions they put on access to those medicines. Using the online plan finder CMS provides to beneficiaries to evaluate drug plans, LTCPA compared how below benchmark plans covered 10 drugs commonly prescribed to long-term care residents. The results varied dramatically from very good to very poor. In New York, for example, there are roughly 80,000 low income nursing home residents who can choose to be enrolled in any of 13 below benchmark plans.
• 3 of those 13 plans cover all 10 drugs, and have restrictions such as requiring prior authorization or step therapy on only one drug.
• 10 of those 13 plans do not cover all drugs, with 2 of the plans not covering 4 of these drugs; and requiring prior authorization or step therapy for an additional 4 drugs.
No single drug plan is best for all nursing home residents all the time. Recognizing that, the Part D program allows low-income nursing home residents to choose among any below benchmark plan, and to switch plans monthly in order to guarantee the best coverage. In spite of the ability to select and change plans, few frail elderly nursing home residents do so. Because nursing home residents are typically very elderly and in poor physical and mental health, most lack the ability to evaluate, choose and enroll in a Part D plan on their own.
To ensure nursing home residents receive some drug coverage, the federal government automatically assigns a plan to all low-income beneficiaries who fail to choose one on their own. Those beneficiaries are evenly – and randomly – distributed among all below benchmark cost plans in the region. That assignment is made without any attempt to match beneficiaries to the plan that best covers their drugs. As a result, while most regions have below benchmark cost plans available to cover all or most of a beneficiary’s medicines with few restrictions, the odds are poor that they will be randomly assigned to that particular plan. Making things worse, it is current federal policy that “under no circumstances should a nursing home require, request, coach or steer any resident to select or change a plan for any reason.” The same prohibition has been applied to other caregivers including pharmacists, nursing home staff and physicians.