Medicare Drug Program Suffers Technical Problems

SUSAN DENTZER:

Barbara Waters was primed for the new Medicare drug benefit that began on Jan. 1. That's because as one of 4 million disabled people on Medicare, the 47-year-old Maryland resident takes 17 different drugs for multiple conditions.

BARBARA WATERS:

I have had epilepsy since I was four. Probably for at least 15 years I have had hypothyroidism. I have had migraines since I was in my 20s. I have got arthritis.

SUSAN DENTZER:

But recently Waters became one of several hundred thousand people snared by start-up glitches of the massive new drug coverage system.

Waters signed up for a private plan offering the new drug coverage last November. But in late December she was notified that a Maryland state agency had enrolled her in another private drug plan.

Worse, it turned out that the plan the state picked did not cover many of her drugs.

BARBARA WATERS:

I was panicked. It's like, I can't do this. This isn't going to cover what I need. And I spent five hours on the phone the next day calling the state, calling Medicare, calling Social Security. And a lot of the time was wait time because you know, all the lines were busy.

SUSAN DENTZER:

Finally reenrolled in the plan of her choice, in early January Waters walked on a broken foot to her local NeighborCare pharmacy but then another glitch emerged. The database used by Waters' drug plan did not show that she was enrolled in a special program called Extra Help for low-income Medicare beneficiaries. As a result, the tab for her share of two prescriptions was astronomical.

BARBARA WATERS:

It came out to $215. That you know, they couldn't give me the prescriptions because I didn't have that money. So I was walking to the pharmacy every day to get one day's supply of the medicine, until the Extra Help part of it is straightened out with my insurance.

SPOKESMAN:

Got a lot of phone calls from people in similar situations.

SUSAN DENTZER:

With the Extra Help Waters expected to pay just $1 to $3 in co-payments for her prescriptions. In desperation, she called her Congressman Democrat Ben Cardin of Maryland. His office contacted the Federal Centers for Medicare and Medicaid services or CMS.

REP. BEN CARDIN:

We called CMS and found that this was a national problem, a national computer glitch. The pharmacists couldn't determine what the right co-payment would be or whether the individual was covered. So we yelled and screamed a lot. We said look, this is life threatening, people need to be able to take their medicines. We can't just say we will fix it next week or next month. You have got to take care of it now.

SUSAN DENTZER:

CMS administrator Dr. Mark McClellan oversees the new drug program in which about a quarter of Medicare's 43 million beneficiaries are now enrolled.

DR. MARK McCLELLAN:

About a million prescriptions a day are now being filled through the Medicare prescription drug benefit.

SUSAN DENTZER:

McClellan says the glitches appear to affect fewer than 5 percent of enrollees. He says they stem from the challenges of transmitting data among computer systems of the government, private drug plans, other information processors and pharmacies.

Most of the people affected are in a group of roughly six and a half million poor elderly or disabled beneficiaries who are on both Medicare and Medicaid. Many are in nursing homes or battling serious chronic diseases, dementia or mental illness.

For years these so-called "dual eligibles" had their drug bills paid for by the states under Medicaid. But with Medicare now taking over their drug coverage, the government took steps last year to make the transition as seamless as possible.

DR. MARK McCLELLAN:

To make sure they all had coverage starting on Jan. 1, they were all automatically enrolled in a prescription drug plan back in early November. Beneficiaries received their drug card, their information was loaded into the computer system to make sure their coverage could start on Jan. 1.

SUSAN DENTZER:

As many as several hundred thousand of these beneficiaries were apparently like Barbara Waters, they did not want the drug plans in which they had been automatically enrolled, often because the new plans did not cover all their drugs.

So many beneficiaries elected to switch plans in the waning days of December just before the new Medicare drug program went into effect. As in Waters' case, the information that they were also eligible for extra help apparently didn't follow them fast enough to their new plan.

DR. MARK McCLELLAN:

As a result, when they go to the pharmacy, they are being charged the wrong co-payment amounts, not the very low co-payments of a dollar or a few dollars for their prescriptions but rather the usual co-payments and deductibles that apply to a person in the program who is not low income.

SUSAN DENTZER:

McClellan says people in about 20 states have been affected, including California, New York, Pennsylvania, Illinois, North and South Dakota and New Jersey. Many of these states have stepped in to pay beneficiaries higher costs in the interim at a tab now running into the millions of dollars. Congressman Cardin is among several lawmakers calling for a legislative fix to compensate states for these outlays.

REP. BEN CARDIN:

We knew that automatic enrollment would create problem for dual eligibles, so no, I think this was all anticipated and Congress needs to respond and correct the mistakes we make.

SUSAN DENTZER:

McClellan says a legislative fix may not be necessary.

DR. MARK McCLELLAN:

What we're focused on right now is ways in which we can work with the states without legislation. And what we've done is to have the states fill in the co-payments that are being charged incorrectly for this subset of beneficiaries. They send that information to us and we can get the information to the drug plans so they can fix the co-payment rate and repay the state.

SUSAN DENTZER:

McClellan emphasizes that beneficiaries caught in these situations have multiple avenues for solving their problems right away.

DR. MARK McCLELLAN:

If they are at the pharmacy, they can have their pharmacist call us at our special toll-free pharmacist line. They can call us at 1-800-Medicare. And if it is an urgent issue, we will assign a caseworker right there to help connect them with their medicines at the right price.

SUSAN DENTZER:

In Barbara Waters' case as with many other Medicare beneficiaries, the problems are gradually being resolved. Waters finally got good news last Friday from her NeighborCare pharmacist Trisha Wattke.

TRISHA WATTKE:

Hey, Barbara. How are you? We got through and —

BARBARA WATERS:

You got through.

TRISHA WATTKE:

And your co-pays are a dollar and $3.

BARBARA WATERS:

You are kidding.

TRISHA WATTKE:

No.

BARBARA WATERS:

Not $215.

TRISHA WATTKE:

No, we got through and you are all set.

SUSAN DENTZER:

Waters told us she is still worried about other issues like the fact that by law Medicare won't cover the critical anti-seizure drug she must take for her epilepsy. But that's a problem that Waters says she will just have to fight another day.