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Medicare drug plan saps help for some

The prescription coverage makes some ineligible for a state program that helps with other medical bills.

By STEPHEN NOHLGREN
Published January 6, 2006


Medicare's new drug benefit began saving money for thousands of Floridians this week, but it also is draining the wallets of some of the state's sickest people.

Julie Kilgore of Homosassa found out Thursday when her normal discount bus ride to the doctor was rejected.

Janet Snell of Pinellas Park figured it out six weeks ago and has been cutting her pill use in half to make them last longer.

Terry Miller of St. Petersburg said she might beg on a street corner and "ask people to save my life, because that's the only thing I can do."

Until Jan. 1, all three women qualified for Florida's Medically Needy program, which helps people whose medical bills overwhelm their incomes. They are usually disabled and chronically ill.

Now the Medicare drug benefit has inadvertently left many of them in a lurch.

"This is virtually a nightmare," said Jeffrey Friedman, whose Broward County company provides drugs to dialysis patients under Medically Needy. "You are going to see people not making it to dialysis because they can't afford it, and you are going to see those people wind up in the hospital."

The Medically Needy program serves about 35,000 Floridians. Their incomes or assets are too high for regular Medicaid. But huge medical bills leave them with little or nothing to live on.

State officials could not provide an estimate of how many Medically Needy people are affected by the change, though it appears to be in the thousands.

For those who are affected, here's how it works:

Each person is assigned a monthly "share of cost," which is usually a few hundred dollars less than their income. Kilgore, for example, receives a Social Security disability check of $742 and has a "share of cost" of $543.

Someone whose medical bills reach the share of cost can go on Medicaid for the rest of the month.

Among other things, Medicaid pays Medicare's copayments and deductibles. And because most disabled people are also on Medicare, the combination of Medicaid and Medicare gives them broad coverage with no out-of-pocket expenses.

Until Jan. 1, prescription drugs helped many people reach their "share of cost" without actually shelling out much money.

Kilgore, 46, takes antipsychotic injections and an arthritis drug that total about $1,500 a month, said her mother, Sally Palmer.

Using those prescriptions, their pharmacist would put Kilgore on the Medically Needy program at the first of the month because she had reached her share of cost. Medicaid would then pay that $1,500 bill, plus all her Medicare copayments and deductibles for the rest of the month.

In setting up Medicare's new drug benefit, however, Congress decided that Medicaid would stop covering drugs for people who also qualify for Medicare. Instead, they were switched to a new Medicare drug plan with no premiums and minor copayments.

But that decision had unintended consequences.

On Sunday, Kilgore was placed on a Medicare drug plan. That meant she no longer had $1,500 in drug bills, so she couldn't reach her share of cost, and her pharmacist could not enroll her in the Medically Needy program.

Now, she must pay her own Medicare copayments and deductibles to doctors and hospitals, as well as pay full bus fare, instead of the discount rides she got under Medicaid.

"The psychiatrist charges $30 every time she sees him to get a prescription for her shot," said Palmer, who is also disabled. Their two disability checks total about $1,000 a month, Palmer said. "This is mind-boggling. The government has dumped us."

The change is particularly hard on dialysis patients. Florida has about 25,000 and roughly 2,000 to 3,000 are medically needy, Friedman estimated.

Until now, their expensive drug bills easily met their share of cost at the first of the month. Then Medicaid would pay $500 to $600 in Medicare copayments for 12 or 13 treatments, he said.

Since Sunday, these patients can't use the drugs to reach their share of cost, don't qualify as medically needy and must pay the Medicare copayments themselves. By the end of the month, the Medicare copayments might pile up enough to meet the share of cost.

But the Medically Needy program does not reimburse people for bills they already paid.

Jonathan Burns, spokesman for Florida's health care agency, said the Medically Needy program has been generous over the years.

"It's important to keep in mind that it's a safety net program, not a primary insurance plan. These people make too much money or have too many assets to qualify for Medicaid," Burns said. "We are going to continue operating Medically Needy as we always have."

Terry Miller, 36, has bipolar disease, joint disorders and painful, prolonged menstrual bleeding called endometriosis. Eight drugs, costing about $1,000, had easily filled her $700 share of cost at the first of every month.

Her monthly $999 Social Security disability check pays her mortgage, utilities, food and maintenance bills with nothing left over, she said. Without Medically Needy, she must shoulder her own Medicare copayments, which run about $30 each for a primary care doctor, psychiatrist, gynecologist, rheumatologist, iron infusions and pain management clinic.

"I'm going to get a bucket and stand on the street with a sign that says, "Please save my life and help me pay for my medication and doctor visits.' What would you do?"

Jackie Snell, 63, and her husband, Robert, 64, are both disabled. Until now, they had no trouble meeting their joint $1,200 share of cost with combined monthly drug bills of about $2,000.

On Jan. 1, Robert Snell shifted to Medicare Part D, removing his drug bills from the share of cost equation. Now her $930 monthly drug bills fall short.

With a family income of only $1,400, she began stocking up on pills in November, by alternating months on her breathing pills. She has chronic lung disease.

"I'm a little bit wheezy," she said Thursday. "But so far, nothing is going on that's bad."