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Friday, November 26, 2021  

Devil in the DetailsPublished 10/3/2005

Like a not-so-catchy show tune, Medicare Part D is about to permanently get stuck in heads across the land. But unlike that show tune, most people won’t be able to remember the chorus, much less the refrain. With a lot of repetition, much of the population will likely ‘get’ the fact that under Medicare Part D, D stands for drugs. This is a helpful nemonic.

The drug benefit means that Medicare will now be offering some insurance coverage for pharmaceuticals. And that is pretty much the end of the straightforward part. Beyond this, 1,162 pages of stipulation/qualification/regulation have been drafted. Hopefully these ‘details’ were NOT designed to discourage elderly and disabled citizens from applying for the program.

I have to commend Eileen Doherty of Senior Answers and Services, for providing a concise overview of the program (Denver Nursing Star, 8/8/05, p. 11; "Low Income Seniors Get Help on Medicare D Parts.") And it is my sincere hope that the program will provide drug coverage for many people who need it.

One of the problems though is that people who meet the low income limits for beneficiary groups 1, 2 and 3 would (I believe) qualify for some type of financial assistance anyway. Drug costs for these folks are usually covered by Medicaid (which is a joint state and federal program). Part D will simply shift the costs. What is more, as so often happens in real life, applicants will end up with an income just above the threshold.

Let me confess that at heart I am a New Dealer. In theory, I believe in popular government programs. Having said that, let’s talk about bedeviled bureaucracy. So far, no reliable solution has been found for this necessary evil, although a naive wish for it to simply go away could be a healthy coping skill.

In a moment of optimism I downloaded a fact sheet about Medicare D, developed by the Coalition of Geriatric Nursing Organizations. I was hoping for a one-page bullet-point deal (that naïve-healthy coping thing again). I did find the tip sheet very helpful, but it’s no quick reference guide. Translating the information for patients will prove (ahem) ‘challenging’ at best. This is no fault of the authors of the tip sheet, as the devil is in fact in the detail of the program itself.

So here are some choice points and key words to remember:

Dual Eligible- Those folks who qualify for both Medicare and Medicaid (Medicaid being the state-federal program for the medically indigent). These beneficiaries will automatically be enrolled into a Part D plan. (Nursing home residents will account for a large percentage of this sector).

Cost Shifting - The slight of hand, frequently seen in health care financing, whereby costs removed from one area mysteriously show up elsewhere. The Medicare-Medicaid shuffle is a classic example.**

(**The shift of Medicaid drug costs to Medicare Part D should serve a number of goals, a primary one being to shield PHARMA from state-imposed cost controls. As we all know, they are quite a poor group. They just have to keep wining and dining physicians and nurses at fancy restaurants in order just to stay afloat. Memo to PHARMA: I bet many nurses and docs (who often don’t even get snack breaks), would be thrilled with submarine sandwiches if they knew you cared as much for patients’ pocketbooks as you do your own. But I digress).

Donut Hole – a low calorie treat consisting of hot air. As applied to Part D, the term is closely related to ‘rabbit hole’: It is hoped that people will not fall into it. Let me quote from the Hartford paper:

"The standard Medicare drug benefit premium will be about $37 a month. There is an annual deductible of $250. After the person has spent that $250, Medicare will cover 75% of the cost of an approved drug up to $2,000.…The next $2,850 in costs are paid entirely by the individual. When the total costs have reached $5,100 ($3,600 out of pocket) then Medicare will pay 95% of all drug costs for the year."

Glazed Over - A term that applies to more than just donuts: It’s what happens to your eyes when you stare too long at the details of Medicare Part D.

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