Nov 29, 2022 - Health

Standalone drug plans broached for frail seniors in community-based care

Illustration of rolls of bills behind a road barricade

Illustration: Natalie Peeples/Axios

Patient advocates are pressing Congress to use the lame duck session to give standalone Medicare drug coverage to some senior citizens who qualify for nursing-level care.

Why it matters: The "fix" would make up for how the Inflation Reduction Act's drug price controls stopped short of applying to the PACE Program, a comprehensive care alternative to nursing homes.

  • The IRA capped out-of-pocket spending at $2,000 annually for seniors using Medicare Part D, but in PACE, all costs are built into one set premium with no copays or deductibles.

Driving the news: A plan from Sens. Thomas Carper (D-Del.) and Bill Cassidy (R-La.) which would enable Medicare beneficiaries enrolled in PACE to access the Part D drug plans and benefit from the price controls in the IRA.

  • "They shouldn't have to choose between the benefits of the PACE program and being able to afford prescription coverage," said Rep. Earl Blumenauer (D-Ore.), who's co-sponsoring a House companion bill.

What they're saying: The lawmakers and patient advocates argue the status quo will leave frail seniors less incentivized to participate in a PACE program and lead to hundreds of dollars more in monthly drug costs.

  • "It's a cost disincentive to enroll in PACE," Peter Fitzgerald, vice president of policy at the National PACE Association, told Axios.

Be smart: The vast majority of PACE participants are eligible for both Medicare and Medicaid, and an October Bipartisan Policy Center report estimates that just 1% of the nearly 62,000 participants in programs around the country are Medicare-only beneficiaries.

  • PACE covers a wider range of services than traditional Medicare, including adult day care, transportation and dental health. PACE organizations serve as both providers and payers for enrollees.
  • Its origins trace back to 1970s San Francisco, when community leaders created a community-based system for elder care. Congress permanently recognized PACE as a provider type in 1997, and 147 organizations operate PACE programs in 32 states as of August 2022.

Yes, but: The proposed bipartisan fix joins a long list of health care policy changes that are in play during the lame duck and may test lawmakers' willingness to tinker with Medicare law.

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