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Top Stories This Week in the Chronicle.
November 25, 2005

New Medicare rules bring trouble for HIV+ people

New federal rules designed to get people off the Medicaid rolls and give senior citizens Medicare prescription drug coverage are causing confusion and may make getting medications more difficult for HIV-positive people.

The new rules, known as Medicare Part D, go into effect January 1. People who need the coverage, and their case managers, are scrambling to choose from HMO-like plans before then. Anyone not enrolled in a program by January 1 will be automatically enrolled in one by Medicare, whether or not that program is right for them.

The changes will hit HIV positive people living on disability with an income between $12,000 and $20,000 per year the hardest, requiring payment of around $4,000 out of their pockets each year to continue getting medications.

Most of the people in this category worked long enough before getting sick to qualify for Social Security Disability Insurance or private disability benefits. Known as dual eligibles, they are also eligible for Medicaid.

According to the advocacy group Treatment Access Expansion Project, there are at least 50,000 people with HIV and AIDS in this group. They are generally poorer and sicker than Medicare-only recipients. Their drugs are currently paid for by Medicaid but will no longer be, under the new plan.

The largest segment of the HIV positive population, people with incomes less than around $12,000 per year who are totally dependent on Medicaid, will not be affected.

Out-of-pocket expenses

Unlike the Medicaid law, which did not allow recipients to be denied medication if they could not pay, patients can now be refused medication for lack of payment.

A Treatment Access Expansion Project booklet says, �The cost containment measures implemented and contemplated by states will have a significant adverse impact on the health of people living with HIV and AIDS and other disabled Medicaid beneficiaries.�

All Part D enrollees will pay monthly premiums of about $37 per month, a new out-of-pocket cost.

Then they will pay the first $250 of their annual prescription cost, known as the deductible. This is also a new cost.

But the big problem starts after that, as the patients will now pay 25 percent of their costs from $250 to $2,250, then 100 percent of the next $2,850.

Above that point, at $5,100, the recipient pays 5 percent of drug costs for the rest of the year.

The segment from $2,250 to $5,100, where the recipient is effectively uninsured, is called the �gap period� or the �hole in the doughnut.�

With drug costs over $2,000 per month, most HIV positive people on the plan will hit that hole in February and March. With their low income, they do not have the money to make those payments.

Non-HIV drugs aren�t on the plan

The other problem is getting the plans to cover other medication, besides anti-retrovirals.

All anti-retrovirals are covered by all the 40 possible plans offered to Ohioans. But people with AIDS take other drugs, often to counter adverse side effects of the anti-retrovirals. Drugs to treat nausea, heart irregularities and diabetes may not be on their plan�s formulary. These ancilliary drugs will have to be paid for totally out-of-pocket.

Some drugs that are in the plans require prior authorization from the insurance company before they will pay.

It is unclear whether or not a person with AIDS can change their plan mid-year if their previous choice becomes unworkable.

Gil Kudrin of Cleveland, 47, who has been positive since 1980, takes five anti-retrovirals and eight ancilliary drugs costing $2,400 per month.

Formerly employed, Kudrin gets combined disability income of $1,466 per month. Currently, Medicaid pays for all of his prescriptions after the state�s drug access plan pays his $700 �spend down,� or premium.

Kudrin said this leaves him with enough to buy $150 per month worth of vitamins and dietary supplements that make him feel better and improve his quality of life.

After the first of the year, Kudrin worries he won�t be able to afford either the prescriptions or the supplements.

�What do you do when people really don�t care whether you live or die?� said Kudrin.

He criticizes the federal government for making the changes to save money.

�To them it�s money they can spend in Iraq or Iran or wherever is next,� he said.

State says no one will do without

Case managers and social workers say the Ohio Drug Assistance Program has told them that no one will have to do without their medication.

Kate Shumate, who directs the program said, �I can assure you that people are not going to go without medications as long as it is brought to my attention.�

Shumate said that as long as the patient load remains at the current level, there is enough state money to cover the new costs.

In the Cleveland area, Title I funds are also available to get people through the coverage gap, but those funds are not available outside that service area.

�The state is not going to let people fall through the gaps [on anti-retrovirals]. said Catherine O�Brien of the AIDS Taskforce of Greater Cleveland. �My biggest concern is the other medications.�

Jason McMinn of Metro Health Medical Center in Cleveland said charity can make up the rest of the cost for some patients.

�The Ohio Department of Health is working with us, case by case, to ensure that the gaps are covered,� said McMinn.

�But where it�s not, people can get rated for charity care.�

McMinn said that people who used to work and thus receive disability insurance, like Kudrin, are �the most concern.�

He�s also concerned that pharmacies can no longer waive co-payments on drug purchases, as they could under the old Medicaid plan.

At the very least, the situation has caused confusion and fear.

Kevin Sullivan of Ohio AIDS Coalition said his clients are �concerned and confused.�

Sullivan thinks the new plan may have some benefit for people who can work because it allows them to work more than the old system did.

�However,� Sullivan adds, �if you were dual-eligible before and now above Medicaid eligibility, this is no little bump in the road.�

Shumate said people need to do things to help themselves and reduce stress, including saving every piece of mail the government sends, carefully picking a drug plan, and communicating issues to case managers and social workers immediately.


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