A life affecting change
Here's a little issue that's also escaped attention. Some people got their drugs for certain conditions (e.g. AIDS) through a combination of state assistance programs and drug company programs. Most of these programs have been ended because they are being rolled into the new Part D program -- although there is much confusion about this, and some pharma companies think they have to end them when they don't according to a new ruling from CMS. Many of those people are going to fall through the cracks in a bad way. Here's this from an AIDS patient in North Carolina.
Here's this from an AIDS patient in North Carolina.
Until the Medicare Part D came into effect I received my medication through the AIDS Drug Assistance Program (ADAP) as well as Patient Assistance Programs from the drug companies. With Medicare D the Patient Assistance programs will no longer exist. Because I am eligible for Part D, ADAP is no longer available to pay for my yearly drug costs of approximately 30,000.
The North Carolina threshold to receive any amount of assistance with the new drug premiums, copays and 'donut hole' is 14,355.00. This is the lowest of all 50 states. I do not qualify for any assistance because I receive 81.00 per year over the threshold.
With an income of 14,355.00 per year I cannot afford to pay out of pocket costs for monthly Part D premiums (approx 35-75.00), the 250.00 deductable, 500.00 of the first 2,250.00 in drug costs, 2,850.00 for the 'donut hole' and 5% of drug costs beyond 3,600.00.
In other words he'll have to pay around $4,000 of his income for drugs, or he'll die. Not a fun choice.
The 2005 Federal Poverty Guidelines show a limit of $9750 for 100% of FPG for a family of one. At 150% of FPG, the income limit is $14,355. This is the same level for all 48 contiguous states and somewhat higher for Hawaii and Alaska. While the NC ADAP has one of the lowest financial eligibility criteria in the country (125% of FPG, or $11,963 for a family of one), the FPG they are using are standard.
There is apparently some reducing factor that is used by NC to determine FPG level because one of their charts indicates that they are using "net" income. The application form shows allowance for "deductions" from gross income, which must be how this fellow seems to have qualified for the program. The question that should be answered now is whether he actually applied for "extra help" for Part D. Even if he is rejected, the documentation for having been rejected can be used when (if) the NC ADAP begins to assist its clients with co-pays, etc. (While such assistance is allowed, it does not count toward TROOP, which is also fairly cruel for people in this fellow's circumstances.)
As for the transitioning issue, if he is not a dual eligible, which his income level says he is not, then I don't quite see how he can be forced off of the ADAP program. NC's ADAP program specifically excluded anyone who has Medicaid coverage; since he wasn't receiving Medicaid, Part D doesn't require him to be transitioned, certainly not immediately. Either he's confused or NC's ADAP is seriously screwing people over.
ADAPs, by the way, are AIDS Drug Assistance Programs, which are funded by the Ryan White CARE Act. States may add more funds to the pot, but usually the largest amount of funding is RWCA (which languishes un-reauthorized). ADAPs are not being rolled up into Medicare Part D, since they often have clients who are eligible for neither Medicaid nor Medicare.
I am, however, confused (and very interested to learn more) about the new ruling on patient assistance programs. I thought that the Office of the Inspector General had made some cockamamy ruling about conflict of interest (maybe not so cockamamy, but I didn't exactly get it) that had the companies all aflutter. If that has changed, I certainly want to tell a few folks in my neck of the woods. Can you be more specific about this?
I do agree that there are some major cracks out there for people to fall through. A lot of them will not be those who qualify for "extra help," even though they are the ones who are getting a lot of concerned attention right now. Those whose incomes are at 200% or even 300% of FPG are going to struggle with Part D.
Thanks for bringing this up. It's given me more to think about.
January 27, 2006 4:36 PM | Reply | Permalink