Medical 2014
by – Sheri de Grom

The Obama Administration (the Centers for Medicare and Medicaid Services) set forth a proposed rule, January 2014. The proposal [Federal Register Vol.79, No 7, Pg1-157] would have brought about broad changes for about 39 million Medicare Part D beneficiaries.


The proposed rule would have ended the practice of covering “all or substantially all” drugs within six classes: antidepressants, antipsychotics, anticonvulsants, antineoplastics and immunosuppressants. This policy, known as the “six protected class” policy, has been in effect since the inception of Part D, and has strong congressional support.

Medicare tried to sell the proposal as a way to save taxpayers money and simplify the Part D program for seniors.

The ‘administration’ has indicated they will revisit their proposed plan and will submit a new proposed rule in the future. When the proposed rule is set forth, EVERY CITIZEN has the right to comment.

You do not need to be enrolled in Medicare to comment on any proposed rule set forth. As an American citizen, you’re entitled to express your opinion on every proposed legislative change. A proposal will become law if not enough citizens can support keeping the law as stated in its current format.

The House and Senate advised Medicare to back off and in a letter drafted by Orrin Hatch (R. Utah), clearly placed on record to Medicare that congressional members (both parties) had strong objections to the Medicare Part D proposals and were concerned the changes would disrupt care and unnecessarily interfere with an already successful program.

It’s important to remember the patients qualifying for coverage by Medicare and Part D are not just those over 65 but also those that are disabled and unable to work. This proposed rule would take away the coverage of numerous drugs necessary for mental health treatment.

I’m confident we’ll see further erosion of Medicare Part D. It’s the only plan within Medicare that helps pay for pharmaceuticals and the patient pays the premium and additional co-pays.

Thankfully, Tom and I have my Federal BC/BS and his Tri-Care for Life for our pharmacy coverage. I don’t believe I’d have the sanity to cope with Part D.

David L. Shern, Ph.D, president and CEO of Mental Health America, said, “These policies fail to acknowledge that physicians and consumers should make individualized treatment decisions, recognizing the unique and non-interchangeable nature of human beings and psychotropic medications, and acknowledging that lack of access to medications has both human and fiscal consequences.”

Medicare’s prescription drug program is widely considered to be a Washington success story. However, the Obama administration is proposing a series of significant changes to fix what critics say isn’t broken.

In my opinion, the continued attempts of Medicare administrators to destroy a program that works efficiently (Medicare Part D), is further evidence that our current administration has no one appointed to a cabinet position with ‘real world’ work experience. Their job security has never been threatened by real world performance standards and customer satisfaction.

The nomination of Robert McDonald, to Secretary of Veterans Affairs, former CEO of Proctor and Gamble, is the first executive with actual public leadership ability who understands what it means to be accountable to stockholders. Taxpayers have not had accountability with other cabinet positions.

I expect to see a newly formulated proposed Medicare Part D Rule submitted within the next six months. If you see the proposal before I do, please let me know. I wish to add my comment to the Federal Register plus express my views to elected officials.

What are your thoughts? Have you had success or problems with Medicare, Plan D? There were a significant number of changes with most insurance plans in 2014. Has your insurance changed their pharmacy coverage?

About Sheri de Grom

Retired Fed/JAG, 5 yrs. on Capitol Hill. Former book buyer for B and N. Concerned citizen of military drawdown. Currently involved in mental healthcare reform, health care strategist and actively pursuing legislative change wherein dual retirees are exempt from enrolling in Medicare at their own discretion without losing tertiary healthcare benefits. Monitor and comment on Federal Register proposed legislation involving Mental Health, Veterans Affairs, Health and Human Services, Medicare and rural libraries. Licensed OSHA Inspector to include Super Fund sites. Full time caregive to Vietnam era veteran. Conceptualized, investigated possible alternatives, authored, lobbied for, and successfully implemented Title X, Section 1095 (known as the Third Party Collection Program of Federal Insurance).
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  1. Thank you again for very important information, Sheri! It still totally confuses me! At the moment, I cut back on a lot of medication and am only purchasing the Synthyroid that I take daily. That is $20 a month at the moment. God knows what will happen in six months!

  2. cindy knoke says:

    Thank you for the info Sheri, albeit discouraging~

  3. This is all so heartbreaking to read. If it ain’t broke, don’t fix it. All I can do is shake my head some more and hope Canada doesn’t screw up our system as I head farther up the road.

  4. inesephoto says:

    Sheri, thank you for sharing. This is a case when knowledge makes me sad and angry.

  5. Patty B says:

    Thank you again for your knowledge in this area. Although I have about 10 years until I need to concern about Part D, since I am on Tri Care as my primary now, I know I will need to have medicare to keep it going, will I also need Part D? But then in 10 yrs who knows how the government will make more of a mess over this. It saddens me to know people suffer because the government doesn’t care nor have a clue about the average American needs because of their inability to govern properly.

  6. Healthcare is so expensive, especially in my country and I can only ponder sad with the current health care provider. almost everywhere, I see hospitals are privately owned and not owned by the government. of course this is very burdensome costs for the economically under the (poor).

  7. Jane Sadek says:

    Thanks for keeping us up on what’s happening in this sort of thing. Of course mental health is as important as physical health. Ineffective or absent mental care is behind most of these shootings that have everyone begging for gun control. Let’s spend less money on controlling American rights and more money on taking care of Americans

    • He Jane – It’s good to see you. Along with the medications for mental health, the other classes of protected medications are of life saving importance. Without immunosuppressants, an immune system can kick into overdrive. When this happens it can and often does kill the individual without proper treatment. Without coverage under Medicare Part D, this medication alone would be at a minimum of $3,000 a month out of pocket.
      I have a series of blogs coming up in the near future titled, Guns, Violence, Mental Health and Suicide. I hope you’ll join me for those discussions. My stand since the Sandy Hook mass shooting has been that if parents would pay attention and interact with their children daily, we wouldn’t be facing many of the horrors we are facing today. What happened to being involved in your children’s lives. At Sandy Hook, mother and son had lived in the same house for 2 years and had not spoken one word to each other. That’s a real red flag. When the less that attentive mother attempted to find something they might have in common, before he stopped communicating, where did she take him but to the gun range. Here he could become more proficient in the use of weapons and stockpile more weapons and ammo. I could go on and on about how the perpetrator was failed by his parents years before he let lose on the innocent victims of Sandy Hook. I place the blame squarely on the parent’s shoulders. They were divorced but they had such wealth, they didn’t have time to care for their son. Does that excuse their son for what he did, absolutely not. However, guns won’t turn us away from mass shootings we are seeing today until children are taught to be responsible adults with values. Unfortunately it’s far too late for many.

  8. ksbeth says:

    thank you for this post, sheri. i cannot even begin to tell you what i went through with the medical insurance wheel of fortune when i became my mother’s conservator and guardian. i went to an elder law attorney who told me, ‘you will have at least 40 things you will have to hurdle and deal with in this arena, and we’ll take it one at a time or you will be overwhelmed.’ she was spot on.

    • Beth – How I wish you hadn’t had to pay an attorney to sort out your mother’s medical insurance issues. It’s really an overwhelming task for someone that doesn’t understand insurance. Sometimes you can find someone willing to help you for free through a local Senior Citizens Center. The individuals that frequent many centers have years and years of experience and they love to have something to do with their time and won’t charge you a dime.
      I’ve never charged for sorting out medical claims. They simply need someone with a trained eye to make sense of what is going on and allows them to help you with it. Make sure you have someone you can trust, That’s the vital component. I will say I’ve never met anyone at the senior center I didn’t trust. Many retired professions show up looking for work to do to help others. You might think about giving it a try if you don’t already have everything sorted out.

      • ksbeth says:

        thanks, sheri. she passed away 2 summers ago, on her 85th birthday, so there’s no more need for it, and i did use some local senior center resources for other areas of expertise, but i learned it was a mixed bag as far as help and understanding. –

  9. Sheri … I have been fortunate to have Medicare and the drug part in particular. I don’t use many drugs, but the two I do take would cost me a great deal more without this coverage.

    Our elected officials are once proving that they react to the lowest common denominator and answer more to the big bucks of special interest than the interest of the average citizen );

    • Florence – One of the crazy making parts of Medicare Part D is that it’s the only Federal Program that doesn’t negotiate price with manufacturers. There’s no provision in the law that allows them to do so, therefore the drug companies can stick the highest price point to Medicare Part D and to the individual paying the co-pay. Who in their right mind allowed this key component to slide past the original legislation?

  10. kanzensakura says:

    Although I am not receiving Medicare, my mother does. I find this of great concern due to medical conditions of the elderly. Many need antidepressants, have conditions that require antipsychotics, have ongoing condition that require uninterrupted anticonvulsants. This is yet another example of how this administration and persons in the congress and senate are so out of touch with the needs of an aging population. Since they have the best coverage in the country, perhaps they need to have their benefits scaled back to save the taxpayers money – and many of their perks as well.

  11. Thank you again, Sheri, for bringing this subject to us. Personally, I have no knowledge or experience of Medicare D and our insurance has not changed since Obamacare. But I find this so intriguing that a plan that is working well (unbelievable) might change and get worse! My goodness, will it ever stop?

    • Patti – When I was reading comments from the medical community (prominent doctors, researchers, medical centers such as Mayo, Scripts, and on and on – everyone was outraged). I’m so thankful Tom and I are not dependent on Medicare Part D (that’s the only portion of Medicare that wasn’t crammed down our throats). I listed an excellent blog in my response to Kanzen above I think you might find interesting. Sheri

  12. My husband and I are not on medicare part D, thankfully. We also have a retirement health plan with an HMO that has pharmacies and affordable cost Rx’s if we need them. To take away antidepressant meds, just that along, will set the stage for more depression going unhandled and more physical symptoms as a result = more drugs for other things that will present. And, not to cover cancer drugs, what’s up with that? It’s a death sentence for many elderly who could be treated and go into remission for many years to come. At my age, that could be me and I just reentered the work force as a part-time NP. Meaning, I’m contributing and you’re telling me if I get the big C that’s it?

    I don’t know what the solution is to this debacle of so many uninsured and the population continuing to grow, while doctors are burning out and leaving practice or not wanting to treat medicaid or medicare patients because of all the red tape and low payments…

    These are important posts, Sheri. I don’t know what the solution is and it leaves me frustrated and very sad when I envision it could be so different.

    • Paulette – Medicare was a great program for our parents. My father was a rancher/farmer in Kansas [big operation] and that was during the time when Roosevelt was saying put all your money in land to farm and increase your herds. This strategy will insure your future. Of course the WWII generation was happy and rightfully felt successful when they could annex 680 acres to adjoining property and expand crop and pasture space.

      However, no one talked about the spiraling cost of keeping a huge operation going 24/7 and the sacrifices required. Dad was up many a morning by 4:00 a.m. to head out the door to ride the pastures to check on downed cows and calves and the never ending job of feeding properly and working the land and trying to keep the books balanced.

      Thus, when Dad retired at 87, his social security was $332/mo. By that time, family farms were no longer being passed on to the next generation. Farm after farm was hitting the auction block and foreign corporations were buying them up. These were farms that had been in families 5 and 6 generations. However, because there had never been enough money for medical insurance what with providing a college education for 6 kids, and my mother needing 4 open-heart surgeries – there was so much debt against the acreage, there was no way to go but sell.

      Interesting enough one of my brothers was able to buy the farm when it hit the auction block. Needless to say there’s a bit of bad blood between the two of us. I’ve always wondered why he couldn’t have saved our father the dignity and I would have gladly signed the papers to allow my brother to have the place when Dad said he couldn’t handle it any longer.

      None of our neighbors had insurance the years I was growing up in rural Kansas. Unless it was really bad, you sucked it up and went on about your business.

      Speaking from observation, that generation benefited from Medicare. It was still operating under the guise of physicians ordering medical procedures and Medicare didn’t ask questions or say they wouldn’t pay or kick people out of the hospital much too early.

      Today, Medicare is rapidly becoming a death squad. Once I’m over my anger, I’ll be blogging about Tom’s emergency heart surgery earlier in the month. The problem would have killed him but Medicare is requesting doctors to cut down on the procedure, especially for those patients over the age of 65. It’s crazy making to me, Medicare won’t release us to use the insurance we already have but neither do they want to allow appropriate medical care.

      We definitely have concerns to be addressed.

      • Oh how sad about your father’s farm. Heart break. My parents were working people from your father’s time so I am with you about how well medicare worked for them back then. It was a different time, a different generation, and a different way “we” took care of each other back then.

        This is another one we could sit down and spend hours talking about and even more about family stories. For now, I’ll just wish you a peaceful weekend and thank you again for this most important post and feedback which is so appreciated.

        • Wow, Paulette. After I replied to your comment I decided to send myself to the garden to dig! I had no idea how much rage I still had built up inside. Tom was wonderful about supporting Dad and making his life special. Definitely something none of my brothers had any idea how to do.
          Isn’t it interesting how we all grow up in the same household and come away with such different values. Not a day goes by that Tom and I don’t have some wonderful memory come to mind about Dad and the years he was in and out of our home. It is indeed the greatest gift Tom could have ever given me.
          Have a blessed weekend, Paulette. Gee, I wish we could sit and chat about this and that and other things too. I wonder what a blogging reunion of sorts would look like?

  13. FlaHam says:

    Sheri, Like you I am covered by FED BC/BS and have no intentions of ever chasing Med Part D. Having said that and because of that, I am not as aware of what “others” will have to go thru or encounter. Our leaders continue to find ways to make “Dumb and Dumber” look brilliant. Over the last few months I have had the endless spam, junk mail and phone calls. Thankfully my decision had been made, A and B is all I need. You as always write wonderfully thought provoking articles. Thanks, Bill

    • Bill – You and I are so fortunate in that we were smart enough to hang on to our FED BC/BS when we retired even if our premiums went up. I consider it a golden investment.

      Another position the Medicare Administration is grumbling about is having to pay pharmaceuticals for patients with Hospice care. That one really crawled under my skin. There reasoning is they only approve medications that improve and sustain life. I’m wondering if this one will make it to the Administrative Law stage for comments.

  14. Elyse says:

    I’m no help here, Sheri. I plan to die before I have to figure out Medicare.

  15. Sheri, as I’m not an American I can’t really comment on this but i do understand that medical issues are real concerns.
    My best to you always

  16. gpcox says:

    I have 13 months to learn the ins and outs of Medicare, Sheri. Hopefully, my better half will have better luck in understanding it all. From the looks of things it’s going to be a mess.

  17. Gallivanta says:

    Sheri, I don’t know enough about this subject to comment on it, but what I do know is that it is very important for people to be aware of what legislation or changes their Governments are proposing. As you will have seen from my latest post, which mentions FATCA, US legislation has far reaching consequences, which Americans themselves might not be aware of. FATCA is not the only American initiative that is affecting our lives in NZ. Wherever we live, we need to be vigilant and keep our elected representatives accountable.

    • Gallivanta – Yes, yes and yes. You are so right. Yes, I saw the mention of FATCA and thought to myself, why? Proposed regulatory rules for allowing laws to be changed were established to make changes to existing laws in order to move legislation along and not having to go through congress. Of course the problem is the regular citizen rarely takes the time to stay informed of what’s going on in the ‘Regulatory/Administrative Law process.’ I don’t like the way the system works but it would work a lot better if more citizens took part. Thanks for coming along for the ride and for the comment.

      • Gallivanta says:

        You are certainly doing your part to be a good citizen.

        • I believe that’s our responsibility. I see you doing the same, often. You already have me wanting to visit your part of the world someday and I hadn’t thought much about it before when I was all over the place!

          • Gallivanta says:

            One day, you will be a welcome guest. Mmmm, belatedly, someone has asked for information about FATCA under our Official Information Act. The information shows that capitulation to American demands was wholesale with no appropriate discussion in our relevant parliamentary committees. Just as FATCA didn’t go through the relevant American committees! Our opposition members in Parliament are now complaining. And the information has come to light that compliance with the American legislation is going to cost our Government $12 million NZ over the next 5 years and $2 million every year after that. And that is just the Government costs. It doesn’t include the costs to banks etc. Imagine how our health system could have better used that $12 million. We are not a rich country; every dollar is valuable.

  18. Pingback: FU,CMS | Another Hope Entirely

  19. Hope says:

    I’m someone who regularly takes both antidepressants and immunosuppressants, this has me worried too. I could live without my antidepressant, but being denied my immunosuppressants would probably kill me. I’m disabled and get just over $700 a month for SSI/SSDI, and my two immunosuppressants alone would cost nearly $3000 per month. And even though these drugs are technically covered by my Part D plan, it’s always a fight to get them approved, involving prior authorization, denials, and numerous appeals. It took almost 3 months to get one of them approved, so I just had to suffer through it. When I needed an additional drug to counteract the side effects of one of the immunosuppressants, I had to fight for several months to get that approved. It’s a constant battle, and it’s even harder to handle when I’m constantly sick. I’d have to disagree with your statement that Part D is a program that works efficiently. It’s certainly better than having no prescription drug coverage, but it has a LONG way to go before it becomes efficient.

    I’ll definitely be communicating my objections to this change to CMS and to my Senators and Representatives. (They’re probably sick of hearing from me by now, but that’s okay by me. I worked on the campaigns for both my Senators, so I don’t feel bad about sending emails to them.)

    • Hope – The change hasn’t been made yet nor is there a proposed new rule. When it does come, it will be a regulatory administrative rule. I’ll be watching for it and hope you will also. It’s congress that believes Medicare Part D and not me that believes the Part D is a success. I don’t consider any part of socialized medical care successful and that’s what Medicare is.
      My closest friend has to deal with Part D all the time and it’s a nightmare. Then there’s the hole you all fall into when you reach a certain level and have to pay for all your prescriptions on your own until another level is met. I don’t know much about that portion of Medicare Part D other than who has that type of extra cash each month!
      It’s insane to have to wait for approval from an administrative person for one or more of your prescriptions to be filled when clearly your physician has prescribed it. I do not believe an administrative type should interfere in a patient/physician treatment plan.

  20. mihrank says:

    wonderful article, I enjoyed it very much!!

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