Many of us in the health care field still remember midnight on December 31, 1999, because we were up well past our bedtimes waiting for massive computer failures and utter chaos to befall our health systems—an event that, thankfully, never occurred. Unfortunately, those of us who are involved with Medicaid P&T committees will not experience the same “non-event” at midnight on December 31 of this year. At this predetermined time and date, beneficiaries whose costs for prescription drugs were covered by both Medicaid and Medicare (“dual eligibles”) will be moved from their Medicaid program to newly formed Medicare Prescription Drug Plans (PDPs).

This change is the result of the Medicare Modernization Act (MMA), which terminates federally funded Med-icaid prescription drug coverage for all dual eligibles, whether or not these individuals obtain coverage through a Medicare Part D plan and whether or not their new Medicare coverage is as broad as their state’s Medicaid coverage. This effect will be felt well after the clock strikes midnight this New Year’s Eve. canadian pharmacy viagra

Table 1 Focus of Medicaid Programs for Dually Eligible Beneficiaries

• Ensure continuity of health care through enrollment in a Medicare drug plan.
• an explanation of how to choose a Medicare PDP
• the name of the Medicare PDP in which beneficiaries will be enrolled if they do not choose a plan by December 31, 2005
• the plan’s Web site and toll-free telephone number for members (1-800-MEDICARE)
• reminders that Medicaid drug coverage ends on December 31, 2005
• a notice that enrollees qualify for extra help with their drug plan costs
• a note that enrollees can change plans at any time
• an explanation of the right to decline Part D. (If Part D is declined, beneficiaries may be subject to a late enrollment penalty if they eventually enroll at a future date.)

The main effect of this massive shift will be felt directly by those individuals who are dually eligible. To be classified as a dual eligible, an individual must qualify for both Medicare and Medicaid separately. For Medicare, the person must be 65 years of age or older, disabled, or with end-stage renal disease. For Medicaid, the person’s income must be below the poverty line and the person must have minimal assets. As a result of these qualifications, the dual eligibles tend to have more extensive health care needs than other Medicare beneficiaries:
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• More than 70% of dual eligibles have annual incomes below $10,000, compared with 13% of all other Medicare beneficiaries.
• Dual eligibles are more than twice as likely to be in fair or poor health (52%) as other Medicare beneficiaries (24°%).
• Nearly 25% of dual eligibles reside in long-term care facilities; only 2% of other Medicare beneficiaries live in such facilities.
• Dual eligibles are more than twice as likely to have Alzheimer’s disease as other Medicare beneficiaries (6% vs. 3%), are substantially more likely to have diabetes (24% vs. 17%), and are more likely to have had a stroke (14% vs. 11%).

Because of these characteristics, dual-eligible beneficiaries are more likely to suffer adverse health consequences if they cannot obtain medications in a timely manner.

These concerns were raised early in this process; just before the MMA’s completion, the Kaiser Commission convened Medicaid directors from eight states in a focus group conducted on October 26, 2003. The group identified the following problems:
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• limited fiscal relief
• major new responsibilities for administering Medicare’s low-income subsidies
• a loss of control over prescription drug benefits for dual eligibles
• a possible prohibition on using Medicaid to supplement the Medicare drug benefit

Although some of these issues (such as the prohibition on using Medicaid to supplement the Medicare drug benefit) have been clarified, significant problems remain. Medicaid programs and their P&T committees will need to refocus their efforts for this frail population. This renewed focus should concentrate on the areas outlined in Table 1.

Although the auto-enrollment is in place to ensure that the dual eligibles have a replacement for their Medicaid drug coverage as of January 1, it does not ensure access to the same level of coverage that these frail individuals might have enjoyed previously.
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