Medicare provides health insurance for Americans age 65 and older, and to younger people with disabilities. More than 570,000 adults age 65 and older live with epilepsy, and that number is rising rapidly as the baby boomer generation enters retirement age. Additionally, many individuals under age 65 living with epilepsy are Medicare beneficiaries due to their disability status. The Medicare program is comprised of four parts:
- Medicare Part A covers hospital care and other skilled non-routine care, including nursing home and skilled nursing care, hospice care, and home health services.
- Medicare Part B covers medically necessary and preventative services, including care to diagnose or treat a condition.
- Medicare Part C (Medicare Advantage) plans offer Part A, Part B, and Part D (described below) benefits in one plan
- Medicare Part D covers many prescription drugs,
Medicare Part D & the Six Protected Classes
The Epilepsy Foundation strongly supports Medicare Part D’s Six Protected Classes policy which ensures greater protections for six classes of medications, including anticonvulsants for epilepsy. Epilepsy medications are not interchangeable, and beneficiaries often react quite differently to the available treatments. People living with epilepsy need meaningful access to the full range of therapies available, and the specialists who know how to prescribe them. When people living with epilepsy are forced to switch medications, or alter their treatment plan, it can lead to breakthrough seizures, associated complications and costs, or even death.
Despite the intent of the Six Protected Classes policy, Medicare Part D beneficiaries living with epilepsy confront barriers to care due to utilization management activities, including high cost-sharing, that limit access to lifesaving epilepsy medications. A 2013 study by Avalere Health found that Medicare Part D plans provide lower levels of coverage for anticonvulsants than commercial health insurance plans.
Learn more about our advocacy efforts to preserve the Six Protected Classes.
MedPAC Recommendations to Congress Would Weaken Access to Care in Medicare
The Medicare Payment Advisory Commission (MedPAC) has issued a number of recommendations that would weaken access to care in Medicare Part D. MedPAC has recommended removing two of the six protected classes, increasing copays, and other proposals that will negatively impact beneficiaries who rely on Part D. We strongly oppose MedPAC’s recommendations to eliminate two of the six protected classes.
Sens. Grassley and Brown Letter on Six Protected Classes
Partnership for Part D Access Press Release on Final MedPAC Recommendations
Senators Urge CMS to Keep Six Protected Classes in Drug Benefit (Bloomberg News)
Medicare Proposal Jeopardizes Access to Care
On May 10, 2016, the Partnership to Improve Patient Care (PIPC), of which the Epilepsy Foundation is a Steering Committee member, sent a letter to the Centers for Medicare and Medicaid Services (CMS) expressing concern about a proposal that would limit a physician's ability to determine the best medication and treatment for his/her patient, by allowing the government to determine the value of a treatment using cost-effectiveness data. The proposal not only threatens access to care for those living with disabilities and chronic conditions like epilepsy who rely on Medicare, but also would set a troubling precedent that extends beyond Medicare. The letter was signed by more than 80 groups, including the Epilepsy Foundation and 25 Epilepsy Foundation affiliates. You can read the full letter below.
PIPC Medicare Payments Comments Group Sign On
Group Sign On Opposing CMMI Part B Proposal
Group Letter to Sen Finance Opposing Part B Demo Proposal
Legislation Would Secure Access to Six Protected Classes
In March 2015, Senator Charles Grassley (IA) and Senator Sherrod Brown (OH) introduced the Medicare Formulary Improvement Act (S 648), legislation to strengthen the Six Protected Classes in Medicare Part D. Epilepsy medications are part of a protected classes in the Medicare program and the Epilepsy Foundation has strongly supported steps to maintain this important patient protection. The Partnership for Part D Access, of which we are a member, was instrumental in securing the introduction of S 648.
Epilepsy Foundation Letter of Support for S. 648
Partnership For Part D Access Press Release on S. 648
Senator Sherrod Brown Press Release on S. 648
CMS Proposal Would Have Eliminated Three of the Six Protected Classes
In January 2014, the Centers for Medicare and Medicaid Services (CMS) proposed a rule to scale back the Six Protected Classes in Medicare Part D to only three classes. The Six Protected Classes policy has enjoyed strong bipartisan support since its inception in 2006, delivering medication to the most vulnerable and costing less than projections from the Congressional Budget Office (CBO) had initially suggested. The Epilepsy Foundation joined with many other organizations and Congressional leadership to oppose these changes, and in March 2014 the Centers for Medicare & Medicaid Services (CMS) announced that they would not move forward with the proposal to eliminate three of the classes. However, there is no guarantee that the agency will not propose a reduction in the future.