[Congressional Record Volume 150, Number 66 (Wednesday, May 12, 2004)]
[Senate]
[Pages S5373-S5375]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mrs. Lincoln, Mr. Daschle, Mr. 
        Lautenberg, Ms. Stabenow, Mr. Kennedy, and Mrs. Clinton):
  S. 2413. A bill to amend title XVIII of the Social Security Act to 
provide for the automatic enrollment of medicaid beneficiaries for 
prescription drug benefits under part D of such title, and for other 
purposes; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, today I am introducing legislation 
entitled the ``Medicare Assurance of Rx Transitional Assistance Act of 
2004'' with Senators Lincoln, Daschle, Lautenberg, Stabenow, Kennedy, 
and Clinton. The bill would assure that all 700,000 low-income seniors 
and people with disabilities who are currently enrolled in a Medicare 
Savings Program (MSP) receive the $600 in transitional assistance in 
2005 and 2006 available to them through passage of last year's Medicare 
prescription drug bill.
  On April 2, 2004, I wrote a letter with 10 other senators to Health 
and Human Services Department Secretary Tommy Thompson urging his 
department to automatically enroll all MSP beneficiaries, which are 
those low-income people currently enrolled in State Medicaid programs 
to assist them with Medicare out-of-pocket expenses, into a Medicare 
drug discount card in order to receive the $600 subsidy available under 
the Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (MMA).
  In light of the fact that there is growing evidence that the savings 
offered via the drug discount card may be either minimal or illusory, 
the only clear benefit is the $600 in transitional assistance that is 
offered to individuals whose income is less than $12,569 this year or 
to married couples whose income is less than $16,862. For those MSP 
beneficiaries who do not have prescription drug coverage, they clearly 
meet the income criteria under the act and their automatic enrollment 
is the only way to assure that they will receive the $600 subsidy that 
was intended for them.
  When the prescription drug bill was passed, the administration 
claimed that they would enroll 65 percent of those eligible for the 
$600 in transitional assistance into the drug discount card. According 
to the Centers for Medicare and Medicaid Services, or CMS, the agency 
expects a total of 5 million of the 7 million eligible to enroll, 
including 29,000 of the estimated 45,000 in New Mexico who would be 
eligible. Under CMS's assumptions, these beneficiaries would save a 
total of $5 billion nationally and $35 million in New Mexico over the 
2-year period.
  Unfortunately, due to a poor advertising campaign which has been 
criticized by the General Accounting Office where ads have run in 
Capitol Hill newspapers such as Roll Call and The Hill, which are not 
normally subscribed to by low-income senior citizens or people with 
disabilities, very few people even know the $600 subsidy exists. 
According to a recent national survey by the Kaiser Family Foundation, 
only 18 percent of senior citizens are aware that the low-income 
transitional assistance program was included in the Medicare 
prescription drug bill. It is hard to believe that 65 percent of those 
eligible will enroll when less than one-fifth of them even know it 
exists.
  Fortunately, CMS has already laid the groundwork for auto-enrollment, 
as just two weeks ago the agency issued guidance for how state pharmacy 
assistance programs, or SPAPs, can automatically enroll their members 
who have income below 135 percent of poverty in the low-income 
assistance. Second, CMS created a standardized enrollment form for low-
income assistance to be accepted by all companies offering Medicare 
drug discount cards. Now, CMS can take a third step to automatically 
enroll MSP members who do not have prescription drug coverage.
  Although I believe CMS has the authority to take this third step on 
its own, the legislation I am introducing today would clarify and 
ensure low-income seniors and people with disabilities receive the 
transitional assistance promised them by the Administration and 
Congress. As the Medicare Rights Center asks, ``Given their definite 
eligibility and clear need for help to pay for their prescription 
drugs, why not save these people and the government the hassle of 
application and automatically enroll them?''
  Some in CMS have argued that this might somehow limit the ``choice'' 
of a low-income Medicare beneficiary. this stated concern is 
inaccurate, however. As the Medicare Rights Center adds, ``Nothing 
would prevent members of MSPs from voluntarily enrolling in the low-
income assistance and picking a drug discount card before automatic 
enrollment began. Even once enrolled in the transitional assistance, 
individuals would enjoy access to the same broad range of prescription 
drugs, since the $600 in annual assistance is not limited to the 
medicines on any specific card's formulary.''
  As for the value of having the ``choice'' of choosing among the 73 
competing drug cards, that is far less valuable than insuring that 
people get the $600 subsidy. According to a story in this morning's New 
York Times entitled ``73 Options for Medicare Plan Fuel Chaos, Not 
Prescriptions,'' that highlights that for many retirees the plethora of 
discount cards is complicated, overwhelming, and not too helpful. 
Florence Daniels, an 85 year-old retired engineer, says she cannot use 
the government website to compare drug costs because she cannot afford 
a computer. She said, ``I'm trying to absorb all the information, but 
it's ridiculous. Not just ridiculous, it's scary. If there was a single 
card and it was administered by Medicare, and it got the cost of drugs 
down--wonderful, marvelous. But with these cards, the only thing we 
know is that we'll have to pay money to other people to administer what 
we can get and can't get.''

[[Page S5374]]

  The interim final rule made available on December 10, 2003, describes 
a process where low-income Medicare beneficiaries will have to apply 
for assistance with one of the newly established drug discount cards. 
There are a number of low-income seniors and people with disabilities 
that are very sick, have cognitive and mental illnesses, and do not 
have access to or comfort with the Internet. Many will wrongly slip 
through the cracks and fail to get the $600 subsidy that they could 
benefit from unless we act.
  In such cases, if an individual has not enrolled for whatever reason, 
it begs the question as to what ``choice'' automatic enrollment would 
take away at that point? Many low-income seniors or the disabled will 
not even be aware of the drug cards or the $600 subsidy for which they 
qualify.
  As a result, by mid-August, either CMS or the states should take the 
affirmative step of automatically enrolling them into the program. If 
we fail to assist them in this manner, what is really lost is not 
``choice'' but the $1,200 in real prescription drug assistance that 
they qualify for and could receive. As a Kaiser Family Foundation study 
last year indicated, Medicare beneficiaries with no drug coverage were 
nearly three times more likely than people with drug coverage to forego 
needed prescription drugs.
  While CMS has estimated that 65 percent of the eligible low-income 
beneficiaries will sign up, that goal will not be met unless some 
proactive steps are taken. Our goal should be to leave none of our 
Nation's low-income seniors and people with disabilities behind. 
Anything less should be considered unacceptable.
  While some of the proponents of the drug discount card have been 
critical of those that have questioned whether the drug discount card 
offers real discounts, they needlessly have tried to make this a 
partisan issue when it is not. There are legitimate and important 
public policy questions as to how effective the prescription drug 
discount card will be.
  However, no matter whether you think the card offers real savings or 
not, everybody should be able to agree on the point that the $600 
subsidy should be provided to as many low-income Medicare beneficiaries 
as possible.
  As a result, I once again call upon the Administration to take this 
important step itself. If it fails to do so, I hope that congressional 
leadership will see fit to move this legislation as quickly as 
possible. There is over $1 billion in prescription drug assistance for 
many of our Nation's most vulnerable citizens at stake.
  I ask unanimous consent that the text of the April 2, 2004, letter to 
Secretary Thompson, today's New York Times article I cited in my 
statement, and the text of the bill be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:


                                                  U.S. Senate,

                                    Washington, DC, April 2, 2004.
     Hon. Tommy Thompson,
     Secretary, Department of Health and Human Services, 
         Washington, DC.
       Dear Mr. Secretary: As the Administration prepared to 
     implement the new prescription drug card, we urge CMS to use 
     a combination of provisions in the new Medicare prescription 
     drug law to make an immediate, major and dramatic improvement 
     in the level of help for low-income Medicare beneficiaries.
       Specifically, we urge you to use the authority in the new 
     law to automatically enroll all current Medicare Savings 
     Program (MSP) beneficiaries (QMB, SLMB, and QI-1 individuals) 
     in the transitional assistance and special transitional 
     assistance programs, thus making these individuals 
     automatically eligible for the $600 per year in low-income 
     discount card assistance without requiring a separate time-
     consuming and inefficient enrollment process. Under this 
     proposal, the current MSP beneficiaries would be told about 
     the new discount cards serving their area and asked to make a 
     selection by mailing a postcard back. If the MSP beneficiary 
     does not make a selection, they can be assigned at random to 
     a plan serving their area.
       Despite years of work and millions of dollars spent on 
     outreach, the level of participation in the MSP programs is 
     very low. The millions of eligible low-income Medicare 
     beneficiaries who are not enrolled in the MSP program miss 
     out on the Part A and Part B deductible, co-pay, and premium 
     assistance provided by these MSP programs. In 2004, this 
     assistance is worth a minimum of $799 and for Qualified 
     Medicare Beneficiaries who live on incomes under 100 percent 
     of the poverty level, it can easily be worth much more than 
     that.
       The interim final rule made available on December 10, 2003, 
     describes a system where low-income Medicare beneficiaries 
     will have to apply for assistance with one of the new 
     endorsed discount card companies. This is a population of 
     seniors and people with disabilities that is often very sick, 
     that often has cognitive and mental illnesses, and that often 
     does not have access to or comfort with the Internet. In 
     short, it is a very difficult population to reach out to and 
     enroll in a new program.
       By automatically enrolling the MSP population, about 
     700,000 individuals will be immediately enrolled. The 
     millions of dollars in outreach, education, and paperwork 
     expenses thus saved can be used to target and outreach to: 
     (1) those eligible beneficiaries not currently in the MSP 
     programs; and (2) to the 2.5 million low-income who live on 
     incomes below 135 percent of poverty but who do not qualify 
     for MSP. Hopefully, when those eligible for the MSP who are 
     not currently enrolled are signing up for the prescription 
     drug discount card program, they can also be enrolled in the 
     MSP.
       Mr. Secretary, you have estimated that 65 percent of the 
     eligible beneficiaries will sign up for the low-income 
     assistance. You goal should be to leave none of our nation's 
     low-income seniors and people with disabilities behind. 
     Anything less should be considered unacceptable.
       Thank you for your consideration of this important request.
           Sincerely,
         Jeff Bingaman, John F. Kerry, Joseph I. Lieberman, Debbie 
           Stabenow, Charles E. Schumer, Tom Harkin, Blanche L. 
           Lincoln, Ron Wyden, Christopher J. Dodd, Hillary Rodham 
           Clinton, Barbara A. Mikulski.
                                  ____


                [From the New York Times, May 12, 2004]

       73 Options for Medicare Plan Fuel Chaos, Not Prescriptions

                            (By John Leland)

       When Mildred Fruhling and her husband lost their 
     prescription drug coverage in 2001, they suddenly faced drug 
     bills of $7,000 a year. Mrs. Fruhling, now 76, began 
     scrambling to find discounts on the Internet, by mail order, 
     from Canada and through free samples from her doctors.
       ``It's the only way I can continue to have some ease in my 
     retirement,'' she said.
       Last week, when the federal government rolled out a new 
     discount drug program, Mrs. Fruhling studied her options with 
     the same thoroughness. What she found, she said, was 
     confusion: 73 competing drug discounts cards, each providing 
     different savings on different medications, and all subject 
     to change.
       ``I personally feel I can do better on my own,'' she said. 
     But she added, ``At this point, I don't think anyone can make 
     an evaluation.''
       Even before they go into effect on June 1, the cards--which 
     are approved by Medicare but offered by various companies and 
     organizations--have been the subject of heated political 
     debate, and AARP advertising campaign about how confusing 
     they are and anxious speculation from those they are supposed 
     to help. Among retirees of different income groups 
     interviewed last week, the initial reaction was 
     incomprehension.
       ``Even the person who came to explain it to us didn't 
     understand it,'' said Mary Shen, 77, at the Whittaker Senior 
     Center on Manhattan's Lower East Side. ``It's not fair to 
     expect seniors, who have enough difficulties already, to have 
     to figure this out.''
       Shirley Brauner, 75, pushed a metal walker through the 
     center's lunchroom. ``All I've got to say is they confuse the 
     elderly, including me,'' she said. ``I'm furious. They're 
     taking advantage of the seniors. How can the seniors 
     understand it?''
       The prescription drug discount cards are a prelude to the 
     Medicare Prescription Drug, Improvement and Modernization 
     Act, which will provide broad drug coverage starting in 2006. 
     The federal government projects that 7.3 million of 
     Medicare's 41 million participants will sign up for the 
     cards.
       Those who wish to do so, however, face the daunting task of 
     choosing the right card.
       ``What it's like is a bunch of confusion,'' said Katharine 
     Roberts, 77, who said she had not been to a movie in six 
     years, in part because of her drug expenses. ``You might find 
     you really need three cards, and you can only choose one.''
       The cards are a 19-month stopgap measure to provide 
     discounts of 10 percent to 25 percent for Medicare 
     participants who have no other prescription drug coverage. In 
     addition, low-income participants are eligible for subsidies 
     of $600 a year.
       The Department of Health and Human Services approved 28 
     companies or organizations to issue cards; among them are 
     AARP, insurance companies and health maintenance 
     organizations. Cards cost up to $30 a year. Each card 
     provides different discounts on different drugs, and is 
     accepted by different pharmacies. Participants can choose 
     only one.
       To help people sort through the options, Medicare and a 
     company called DestinationRx set up a database on its Web 
     site, medicare.gov, that lists the prices charged under 
     various plans for whatever medications a user types in. 
     People can get similar help by telephone at 1-800-

[[Page S5375]]

     MEDICAR. But some providers complained that the prices on the 
     site were inaccurate, and some cards are not listed at all.
       For many retirees, it is too much.
       ``I'm 85, do I have to go through this nonsense?'' asked 
     Florence Daniels, a retired engineer who said she received 
     less than $1,000 a month from Social Security, of which she 
     paid $179 a month for supplemental medical insurance. She 
     gets drugs through a New York State program, which provides 
     any prescription for $20 or less. To make ends meet and 
     afford her drugs, she said she bought used clothing and put 
     off buying new glasses. Some of her friends travel by bus to 
     Canada to buy drugs; others do without, she said.
       Ms. Daniels did not use the government Web site to compare 
     drug cards, in part because she cannot afford a computer. 
     ``I'm trying to absorb all the information, but it's 
     ridiculous,'' she said. ``Not just ridiculous, it's scary. If 
     there was a single card and it was administered by Medicare, 
     and it got the cost of drugs down--wonderful, marvelous. But 
     with these cards, the only thing we know is that we'll have 
     to pay money to other people to administer what we can get 
     and can't get.''
       The discount program, which is financed largely by the 
     cards' sponsors, reflects the Bush administration's desire to 
     open Medicare to market principles without allowing 
     participants to import drugs from other countries, which many 
     Democrats favored.
       Mark B. McClellan, an administrator at the Center for 
     Medicare and Medicaid Services, said the complexity of the 
     plan encouraged competition. ``We're seeing more plans 
     offering better benefits,'' he said, estimating that people 
     will be able to save 15 percent or more using the cards.
       But the complexity of choices will keep many people away 
     from the program, said Marilyn Moon, director of health at 
     the American Institutes for Research, a nonprofit research 
     organization in Washington.
       Often, the discount provided by the cards is not as good as 
     what people can get from existing state programs, union plans 
     or consumer groups, said Robert M. Hayes, president of the 
     Medicare Rights Center, a nonprofit organization that helps 
     individuals with Medicare problems.
       Sydney Bild, 81, a retired doctor in Chicago, compared the 
     discount cards with the prices he paid ordering his drugs by 
     mail from Canada. Dr. Bild pays $4,000 to $5,000 a year for 
     five medications. When he checked the government Web site, he 
     said the best plans were about 50 percent to 60 percent 
     higher than what he was paying.
       But Dr. Bild said his main objection to the new plans was 
     that companies could change prices on drugs, or change the 
     drugs covered. Medicare requires plans to cover only one drug 
     in each of 209 common categories. Consumers can change cards 
     only once a year. Committing to a card is ``like love--
     it's a something thing,'' Dr. Bild said. ``What if I chose 
     one? They could drop my drugs two weeks later.''
       Companies began soliciting customers for their discount 
     drug cards last week. When the first pamphlets arrived at 
     Beverly Lowy's home in New York City, Ms. Lowy said, she 
     looked at them carefully. She does not have drug coverage and 
     last year spent about $3,000 on prescription drugs. But the 
     more brochures she reads, Ms. Lowy said, the less clear 
     things became.
       ``You really have to be a rocket scientists,'' Ms. Lowy, 
     71, said. ``It takes time, energy, and you don't even save 
     money. I thought, `This one is offering this, this one is 
     offering that.' Finally I decided this isn't for me.''
       At the Leonard Covello Senior Center in East Harlem, the 
     new cards seemed opaque. Ramon Velez, 72, a retired taxi 
     driver, said he had watched AARP advertisements in which 
     people read the dense language on the federal Medicare bill.
       ``I was laughing at the people in the ads, but it's true,'' 
     Mr. Velez said. ``Everyone's confused.''
       Mr. Velez received $763 a month from Social Security, and 
     often skips his psoriasis medication because he cannot afford 
     the $45 co-payment under this Blue Cross/Blue Shield plan. He 
     wondered if the new drug cards could save him money.
       ``But it's very confusing,'' he said. ``I'd go to the 
     Social Security office to ask about the cards, but I don't 
     think they'd know.''
       Alejandro Sierra, 67, a retired barber, paced around the 
     center's pool table. Mr. Sierra takes six medications for 
     diabetes and complications from cataracts and colon cancer, 
     and sometimes skips a medication because he cannot afford it.
       ``I'm interested in the cards,'' he said. ``But I can't 
     figure it out on the computer, because I can't see.''
       Carlos Lopez, the director of the center, said the cards 
     had so far produced little but anxiety. Mr. Lopez asked 
     participants to bring any applications to him before signing 
     them, and warned them about people selling phony cards.
       ``They're not nervous, but concerned,'' he said. ``They 
     feel, why now? Why do I suddenly need a card for 
     medications?''
                                  ____


                                S. 2413

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Medicare Assurance of Rx 
     Transitional Assistance Act of 2004''.

     SEC. 2. AUTOMATIC ENROLLMENT OF MEDICAID BENEFICIARIES 
                   ELIGIBLE FOR MEDICARE PRESCRIPTION DRUG 
                   BENEFITS.

       (a) Automatic Enrollment of Beneficiaries Receiving Medical 
     Assistance for Medicare Cost-Sharing Under Medicaid.--Section 
     1860D-14(a)(3)(B)(v) (42 U.S.C. 1395w-114(a)(3)(B)(v)) is 
     amended to read as follows:
       ``(v) Treatment of medicaid beneficiaries.--Subject to 
     subparagraph (F), the Secretary shall provide that part D 
     eligible individuals who are--

       ``(I) full-benefit dual eligible individuals (as defined in 
     section 1935(c)(6)) or who are recipients of supplemental 
     security income benefits under title XVI shall be treated as 
     subsidy eligible individuals described in paragraph (1); and
       ``(II) not described in subclause (I), but who are 
     determined for purposes of the State plan under title XIX to 
     be eligible for medical assistance under clause (i), (iii), 
     or (iv) of section 1902(a)(10)(E), shall be treated as being 
     determined to be subsidy eligible individuals described in 
     paragraph (1).''.

       (b) Assurance of transitional assistance under drug 
     discount card program.--
       (1) In general.--Section 1860D-31(b)(2)(A) of the Social 
     Security Act (42 U.S.C. 1395w-141(b)(2)(A)) is amended by 
     adding at the end the following new sentence: ``Subject to 
     subparagraph (B), each discount card eligible individual who 
     is described in section 1860D-14(a)(3)(B)(v) shall be 
     considered to be a transitional assistance eligible 
     individual.''.
       (2) Automatic enrollment of medicaid beneficiaries.--
     Section 1860D-31(c)(1) of the Social Security Act (42 U.S.C. 
     1395w-141(c)(1)) is amended by adding at the end the 
     following new subparagraph:
       ``(F) Automatic enrollment of certain beneficiaries.--
       ``(i) In general.--Subject to clause (ii), the Secretary 
     shall--

       ``(I) enroll each discount card eligible individual who is 
     described in section 1860D-14(a)(3)(B)(v), but who has not 
     enrolled in an endorsed discount card program as of August 
     15, 2004, in an endorsed discount card program selected by 
     the Secretary that serves residents of the State in which the 
     individual resides; and
       ``(II) notwithstanding paragraphs (2) and (3) of subsection 
     (f), automatically determine that such individual is a 
     transitional assistance eligible individual (including 
     whether such individual is a special transitional assistance 
     eligible individual) without requiring any self-certification 
     or subjecting such individual to any verification under such 
     paragraphs.

       ``(ii) Opt-out.--The Secretary shall not enroll an 
     individual under clause (i) if the individual notifies the 
     Secretary that such individual does not wish to be enrolled 
     and be determined to be a transitional assistance eligible 
     individual under such clause before the individual is so 
     enrolled.''.
       (3) Notice of eligibility for transitional assistance.--
     Section 1860D-31(d) of the Social Security Act (42 U.S.C. 
     1395w-141(d)) is amended by adding at the end the following 
     new paragraph:
       ``(4) Notice of eligibility to medicaid beneficiaries.--Not 
     later than July 15, 2004, each State or the Secretary (at the 
     option of each State) shall mail to each discount card 
     eligible individual who is described in section 1860D-
     14(a)(3)(B)(v), but who has not enrolled in an endorsed 
     discount card program as of July 1, 2004, a notice stating 
     that--
       ``(A) such individual is eligible to enroll in an endorsed 
     discount card program and to receive transitional assistance 
     under subsection (g);
       ``(B) if such individual does not enroll before August 15, 
     2004, such individual will automatically enrolled in an 
     endorsed discount card program selected by the Secretary 
     unless the individual notifies the Secretary that such 
     individual does not wish to be so enrolled;
       ``(C) if the individual is enrolled in an endorsed discount 
     card program during 2004, the individual will be permitted to 
     change enrollment under subsection (c)(1)(C)(ii) for 2005; 
     and
       ``(D) there is no obligation to use the endorsed discount 
     card program or transitional assistance when purchasing 
     prescription drugs.''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect as if included in the enactment of section 
     101 of the Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003 (Public Law 108-173; 117 Stat. 
     2071).

                          ____________________