Maine taxpayers could be asked to pay $23 million or more to fill in the gaps when the federal government takes over subsidized drug coverage for the elderly starting Jan. 1, and that still won’t be enough to keep some seniors from falling through the cracks, advocates say.

The much discussed but hard to understand federal Medicare Part D program essentially takes the administration of a drug benefit for seniors from the state and gives it to the federal government.

The good news is that 150,000 seniors, whose incomes were high enough that they couldn’t receive state assistance to buy their drugs before, can now buy subsidized drug coverage under Medicare. The coverage is actually being provided by private insurers under the Medicare umbrella.

The bad news is 90,000 others, about half of whom were eligible for full Medicaid benefits because of low income and disabilities, and the other half receiving a Drugs for the Elderly (DEL) benefit provided by the state for those between 100 and 185 percent of poverty, are about to see their benefits change.

And, if they do nothing, the poorest could end up in plans that don’t cover the medications they’re currently on and the rest could end up with nothing. As of Jan. 1, state subsidized drug plans, as they now exist, are going away.

“I don’t think I’m being overly dramatic when I say people may die,” said Jude Walsh, the drug expert in the governor’s Office of Health Policy and Finance.

Those seniors currently enrolled in Medicaid or DEL should call 1-866-796-2463 to get help in enrolling in a new plan. Enrollment begins Nov. 15.

Price to taxpayers

At the very minimum, the state will have to come up with $12 million to pay the federal government for taking over the drug benefit even though it was supposed to be a wash, meaning what is being spent on Medicaid now for drug coverage will be spent on Medicare.

The reality, state officials here and elsewhere say, is the feds have done their math wrong, and it will end up costing Maine to have the federal government run the program. The scarier part is that difference grows every year, and Maine could be paying as much as $35 million annually in the future to the federal government to keep a program going.

Even with the extra money, the drug benefit under Medicare Part D is not as comprehensive for those making less then 185 percent of poverty, or $1,475 a month for an individual and $1,980 for a family of two.

Walsh is working on a plan that would at minimum pay $10.7 million in new drug benefit premiums that will be charged to the elderly poor under Medicare Part D. She is being pushed to recommend more state-funded subsidies on an advocates wish-list that adds up to tens of million of dollars.

The biggest chunk, by far, would be paying drug costs that exceed the new federal limit of $2,250 per year for persons with incomes above 150 percent of poverty. When a Medicare Part D participant hits that cap they will get no coverage until they’ve spent an additional $2,850 out of their own pocket. Once they’ve spent through what is commonly called the “doughnut hole,” full drug coverage kicks back in.

To cover that gap for the state’s elderly poor, if they all hit the ceiling, would be a huge expense.

“Pay the doughnut hole for everybody and you’re at $60 million,” Walsh told a group of advocates at a meeting last week.

While Walsh is trying to keep under control cost requests that will be made to the Legislature in a supplemental budget early next year, some advocates say that’s not her job.

“The commitment was to try and hold people harmless and let the Legislature worry about the money,” said Leo Delicata of Legal Services for the Elderly, based in Scarborough.

The Legislature, in fact, passed a law this past session “To Ensure Continuity of Care Related to Implementation of the Federal Medicare Drug Benefit,” but raised no money for it.

Delicata said no one is expecting 100 percent of the people to hit the doughnut hole, but the real unknown is what necessary drugs won’t be covered under the federal plan, which offers most seniors a confusing array of 16 drug plans to choose from.

“I think everybody understands how critical this is and how many people will be hurt,” if it’s not done right, he said. “Politically, it’s a very hard thing to walk away from.”

What’s changing

Walsh would like to enroll all the state’s current Medicaid-eligible seniors and those getting Drugs for the Elderly assistance now into a new DEL program that would allow the state to manage their drug benefits under Medicare Part D.

To do that the attorney general has said the state has to pay any premiums charged by the Medicare plans – the $10.7 million. It also needs to get the state’s elderly poor to enroll in Medicare Part D, because the state plans are going away. The only people automatically enrolled are the poorest, or those making under 100 percent of federal poverty.

And, time is running out.

As of Jan. 1, the DEL program, as it now exists, ends. Those covered by Medicaid now will be automatically enrolled in a Medicare plan that may not cover all of the drugs they’re currently using.

If the state continues to manage their plans, Walsh said, they will get help choosing coverage that best matches their needs based on their previous drug regiments. Ultimately that will save the state money, particularly for Medicaid-eligible seniors, because the state is still responsible for their other healthcare costs.

“It leaves the state on the hook for higher medical costs if they go into some sort of crisis situation because they had the wrong drugs,” said Rep. Hannah Pingree, co-chairman of the Health and Human Services Committee.

Those seniors who have never received state subsidized drug coverage will be on their own to choose a plan based on price and prescriptions covered, although advice is available through local agencies on aging or by calling 1-877-353-3771.

Seniors need to review the 16 plans offered through Medicare and make sure they are better than the ones they already are getting through retirement programs or from third-party insurers. The federal government is encouraging those already covered by retirement plans to stay with them, by offering financial incentives to the payers.

State of Maine retirees, for example, are sticking with their state plan because it’s better than what Medicare is offering.

The state, in return, is getting $2.8 million in incentive money for those retired workers, including teachers, but it was spent already by the Legislature earlier this year to balance the budget.


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