June 2, 2005

NEW JERSEY’S FY2006 BUDGET MUST INCLUDE
WRAP-AROUND SERVICES FOR DUAL ELIGIBLES!

Tell our the legislators that we cannot allow 140,000 of NJ’s most vulnerable individuals to lose access to important prescription drugs!

Problem:

Beginning in January “Dual Eligibles” (individuals who are eligible for both Medicaid and Medicare) will have their medications covered by the new Medicare drug benefit. In New Jersey this means that dual eligibles will no longer have comprehensive Medicaid drug coverage, but rather the more restrictive coverage through Medicare. For other than most psychiatric medications, dual eligibles will be restricted to a choice of two drugs in a therapeutic class. For PAAD recipients, New Jersey has created a “wrap-around” that will continue to provide those medications not covered by Medicare. The proposed state budget does not provide a similar wrap-around for dual eligibles who are among our most vulnerable citizens.

Action Needed:

We are asking that everyone send a letter or email to your State Legislators as soon as possible asking them to include funding in the FY2006 budget to cover “wrap-around services” for dual eligibles, the state’s most vulnerable citizens. You can find out who your Legislators are from the NJ Legislature’s website at www.njleg.state.nj.us or 800-792-8630. If you can include a personal story conveying how this issue would affect you, your family, or consumers you know, please do so.

Talking Points:

1. “Dual eligibles” are persons who receive both Medicaid and Medicare benefits. In New Jersey, there are approximately 140,000 dual eligibles. The dual eligibles are, by definition, people who have both very limited incomes and disabling conditions.

2. New Jersey is creating a wrap-around (continued full access to medications) for PAAD recipients, but is leaving vulnerable dual eligibles with only reduced medication coverage

3. Many of the dual eligibles require multiple medications on a daily basis.

4. Because of changes to federal law, starting in January, dual eligibles will be required to pay co-pays for all of their prescription drugs ($1/prescription for each generic drug and $3/prescription for each brand name drug). Also starting in January, dual eligibles will receive their drugs through new plans that use “formularies” -- lists of covered medications. There is no guarantee that if individuals need medications (other than psychiatric medications) that are not on the formulary, they will be able to get them

5. The prior authorization and appeals processes that individuals need to go through may be cumbersome and confusing for this vulnerable population. We know from experience that dually eligible consumers with developmental disabilities will not be able to navigate the bureaucracy necessary to self-advocate when they learn that an urgently needed drug is not covered.

6. For many dual eligibles, this could mean discontinuing medications that have made dramatic differences in their disabling conditions and switching to other medications that may be less effective, or cause additional side effects.

7. If dual eligibles do not receive their medically necessary medications, they are at risk for unnecessary hospitalizations and potentially life-threatening medical complications!

8. New Jersey must cover the “wrap-around costs” for the dual eligibles. There must be funding in the FY2006 Budget to cover the costs of: 1) the medication co-pays, and 2) the medications that the dual eligibles need that are not on the Medicare drug plan’s formulary.