[ MEDICINE ]

Medicare project to
cover drug therapies
for some chronic ills

edicare is conducting a two-year $500 million demonstration project under the Medicare Act of 2003.

Medicare will cover prescription drug therapies for certain chronic conditions. This is a project separate from the current discount drug program.

Participation in the project is limited to up to 50,000 patients with multiple sclerosis, certain kinds of cancer, rheumatoid arthritis, osteoporosis, pulmonary hypertension, secondary hyperpararthyroidism, Paget's disease, hepatitis C or CMV retinitis. The covered prescriptions are those that may be used to "replace" or in lieu of drugs that are currently covered under Part B (medical insurance).

This demonstration project is open to individuals with Medicare Part A (hospital insurance) and B -- including enrollees in Medicare managed care plans -- and Medicare must be the primary payer.

If chosen to participate, the participant must pay the same cost-sharing for the covered drugs as will be required under the Medicare Part D prescription drug benefit when it becomes effective in 2006.

Applications are available on www.medicare.gov and through Trailblazer Health Enterprises, the Medicare contractor that will administer the project.

The contact number is 866-563-5386 or 866-563-5387 (TTY). The applications requires a signed confirmation by the doctor who prescribes the medication.

Disability critical cases

The Social Security Administration has revised its Hearings and Appeals Litigation Law Manual to specify four situations that warrant instituting prompt processing for disability cases where:

>> The claimant's illness is terminal.

>> The claimant is without, and is unable to obtain, food, medicine or shelter.

>> There is an indication that the claimant is suicidal or homicidal.

>> The case has both (1) been delayed an inordinate amount of time (i.e., pending more than 60 days longer than the average processing time for the office in question), and (2) a public, congressional or other high priority inquiry on the case.

Medicare hospice coverage

Medicare hospice benefits are provided under Part A (hospital insurance) of the program. To be eligible for Medicare hospice, you have to be enrolled in Part A. Also the beneficiary must be certified by the hospice physician and the individual's attending physician.

The benefit consists of two 90-day periods each and an unlimited number of subsequent periods of 60 days each. Either the beneficiary or the authorized by state law representative must make election to receive hospice care.

Medicare beneficiaries may elect hospice care for a terminal illness or palliative treatments.

Generally, the patient makes the election for the benefit, problems arise when the patient is incapacitated. You need to check your local statutes to determine who has the ability to make that election for an incapacitated individual.

The hospice benefit covers the following services:

>> Physical therapy, occupational therapy and speech pathology services.

>> Nursing services provided by or under the supervision of a registered nurse.

>> Homemaker services.

>> Home health aide services.

>> Physician services.

>> Medical services provided by a social worker under physician supervision.

>> Medical appliances and supplies.

>> Short-term inpatient care provided in a participating hospice inpatient unit or in a participating hospital or skilled nursing facility.

>> Counseling services to the terminally ill family members and the individual.

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