Gov. rule change could be costly for thousands with chronic illnesses

By Bob LaMendola
South Florida Sun-Sentinel Health Writer
Posted November 10 2006

Because of tangled government eligibility rules, up to 37,000 Floridians with chronic and costly illnesses are at risk of losing low-cost Medicare and Medicaid prescription coverage. As a result, they will face sharply higher medical bills.

Patients and advocacy groups fear the big bills will drain thousands of dollars every month from people who can afford it least, possibly forcing some to skimp on medicine and doctor visits -- for at least a few months.

"I'm just able to scrape by now. If I had to pay more, I don't know what I would do," said Bruce Bernstein, a Boynton Beach heart transplant recipient who is disabled at age 59. "I might lose my home."

The problem springs from complex eligibility rules. These patients -- about 2,000 in Broward County and 1,000 in Palm Beach County -- earn too much to qualify for regular state Medicaid available to low-income people, but because of large medical bills, they were eligible for a state "medically needy" program that paid all their costs.

This year, medically needy patients were moved into Medicare's new drug program, and pay subsidized prices of $0 to $5 per prescription. But because Medicare now covers the bulk of their drugs, most of them no longer will qualify as medically needy on Jan. 1. That's the Catch-22.

As a result, these patients will also lose eligibility for the Medicare discounts and must pay regular drug co-pays.

If that happens, Bernstein said his out-of-pocket costs for drugs would top $1,000 a month, a hard hit to his disability income of about $2,000. Now, in a Medicare HMO, he pays $45. In 2005, on medically needy status, he paid nothing.

Those affected by the change are among the sickest people in the state, with chronic conditions such as organ transplants, HIV/AIDS, cancer and heart disease. Some need more than $3,000 of medication monthly.

State and federal officials said some medically needy people do not realize their special coverage could end on Dec. 31, even though agencies are sending letters and activists are spreading the word.

"There are going to be some very, very upset people, and some are going to be clueless," said Miriam Harmatz, an attorney at Florida Legal Services in Miami. "They're going to go to the drugstore on Jan. 2 to pick up their prescriptions expecting to pay $2 and it's going to be hundreds of dollars."

Florida officials said they do not know how many medically needy patients will be affected or how much they will spend.

Some will be able to remain on the medically needy plan because they still have high bills, and others will re-qualify for subsidized Medicare drug prices because their annual incomes fall below $14,700 ($19,800 for a couple).

But those who do not qualify will lose part or all of their present coverage and will have to hunt for Medicare health plans or drug plans with low premiums and co-pays, said Sybil Richard, assistant secretary for Medicaid operations.

"Some will have problems, but we feel there are options to keep people in good health care coverage," Richard said.

On a positive note, Richard said, those patients who are forced to pay very large medical costs in 2007 can requalify for Medicaid's medically needy program the next month.

Once that happens, they will also requalify for the subsidized drug coverage from Medicare, restoring their present status, said Renard Murray, an associate regional administrator for Medicare.

"It's not dire straits for these folks," Richard said.

But health care advocates remain concerned. Applying and getting reapproved for two government programs could take at least two months, during which time the patients would be paying thousands of dollars out of pocket.

Bill Rettinger, a Fort Lauderdale activist disabled by severe arthritis from an auto accident as well as asthma and diabetes, said his out-of-pocket costs for drugs and doctor visits will top $1,100 per month out of his disability check of $1,300. This year, under Medicare, he is paying about $300 a month.

"I'm figuring out which bridge I'm going to live under," Rettinger said.

Advocacy groups led by the Florida Coalition for Transplant Survivors have started a petition asking state legislators to make it easier to qualify as medically needy. Now, patients do not qualify until their medical bills absorb all but $200 of their monthly incomes.

In addition to Medicaid's medically needy group, other low-income patients are at risk of losing subsidized prescriptions next year. Medicare sent letters to 46,000 Floridians -- 623,000 across the nation -- warning people they will not be automatically renewed for subsidies and must reapply. While a large number of them could easily requalify, officials and advocates worry some people will fail to reapply and lose out, because they mistakenly think they are supposed to be dropped, fail to notice the letter or belong to hard-to-reach groups, such as the mentally ill and homeless.

Bob LaMendola can be reached at blamendola@sun-sentinel.com or 954-356-4526 or 561-243-6600, ext. 4526.