A parity plan for dual eligibles: The Home and Community Services Copayment Equity Act of 2007

It is hard to believe that it was 18 months ago when consumers, pharmacists, and long-term care providers were trying to figure out the new Medicare Part D prescription drug program. Articles were written, directives were issued, hearings were held, and it seemed like everyone you talked to had an opinion about the new program. Progress has certainly been made as consumers and providers alike have started to understand Part D and how it can help seniors. However, there are still some concerns with the program, and one in particular affects assisted living residents.

Before January 2006 and the implementation of Medicare Part D, dual-eligible assisted living residents (those who receive Medicaid and Medicare benefits) were exempted from remitting co-payments for their prescription drugs. The exemption from co-payments was also applicable to individuals residing in skilled nursing homes, as well.

Under the new Medicare Part D program, however, dual-eligible residents in assisted living communities are not exempt from prescription drug co-payments. This has created a severe financial hardship for these residents who are already living on very low incomes. The only discretionary income most of these residents have is a Personal Needs Allowance (PNA)—frequently less than $60 per month. Residents use the PNA to pay for clothing, personal hygiene items, over-the-counter medications, and any other necessary items they need. To have to use this meager allowance to cover prescription drug co-pays is a true hardship.

With the inability of many dual-eligible assisted living residents to afford the new co-payments, thousands of assisted living providers have had to use their personal funds to cover the cost of Medicare Part D co-payments. Pharmacists have also been providing support for residents who cannot afford the co-pay.

Absent the actions of assisted living providers and others, dual-eligible assisted living residents would have been forced unnecessarily into a higher and significantly more expensive care setting, such as a nursing home, where residents are exempt from Medicare Part D co-payments.

The only remedy for this inequity is legislation that would eliminate the co-payments for assisted living residents. In 2006, Senators Gordon Smith, Hillary Clinton, and Bill Nelson introduced the Home and Community Services Copayment Equity Act of 2006, but unfortunately it was not passed.

The bill has been reintroduced this year as S. 1107. The Home and Community Services Copayment Equity Act of 2007 would ensure that qualified assisted living residents and dual-eligible recipients who live in other home- and community-based settings receive the same relief from Medicare Part D co-payments that nursing home residents receive. This bill has tremendous bipartisan support from Sens. Smith (R-Ore.), Nelson (D-Fla.), Jeff Bingaman (D-N.M.), Barbara Boxer (D-Calif.), Clinton (D-N.Y.), Susan Collins (R-Maine), John Kerry (D-Mass.), and Blanche Lincoln (D-Ark.).

Smith has requested that officials from the Centers for Medicare & Medicaid Services (CMS) explore administrative measures that could alleviate the current situation for dual-eligible residents in home- and community-based settings until Congress can pass the necessary legislation. CMS responded that although it empathizes with the plight of these residents, it cannot address the current situation with an administration remedy.

The Assisted Living Federation of America (ALFA) has been working to gain passage of this legislation for two years, but our efforts alone will not make this happen. Residents, family members, staff, and others are encouraged to write their senators and urge passage of S. 1107.

All consumers, regardless of age or income, have the right to live and receive care in the setting of their choice. Without passage of this bill, many dual-eligible beneficiaries living in assisted living or their own homes could be forced to move into a skilled nursing facility simply because they cannot afford the Medicare Part D co-pay for necessary medications.

Write your senator to urge his or her support. Working together we can make sure this does not happen. Act now to gain passage of S. 1107.

Maribeth Bersani is Senior Vice-President for Public Policy for ALFA. For further information, phone (703) 894-1805 or visit https://www.alfa.org.

To send your comments to the author and editors, e-mail bersani0607@nursinghomesmagazine.com.

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