Howard is on dialysis four days a week and has frequent doctor appointments. Four years ago, a virus led to kidney failure and changed his life forever at age 60.

The only option for the retired construction worker from Naples to stay alive is with dialysis and medications. He collects $1,100 in Social Security Disability each month and lives with his son. A kidney transplant isn't possible.

"They said my heart wouldn't make it through an operation," Howard said. "So I'm stuck."

Now he's about to be stuck again.

In preparation of the Jan. 1 start of Medicare Part D, the federal prescription drug program, Florida officials were required to send to the federal government Howard's name, and those of nearly 36,000 other Florida residents who are in the state's Medically Needy program. The program provides Medicaid coverage for individuals who faced a catastrophic illness and who otherwise wouldn't qualify for Medicaid.

After receiving the list, the federal Centers for Medicare and Medicaid would enroll Howard and the others in prescription drug plans through Part D if they don't make their own plan choice. Their medications would be paid for by their prescription plan come January instead of by the state's Medicaid program.

That was all well-intentioned until someone dropped the ball, according to some patient advocacy groups.

Either the state Agency for Health Care Administration didn't send the list of the Medically Needy to the federal agency, or the federal agency failed to send letters to these individuals explaining how they could make their own drug plan choice or leave it up to the federal government.

Most people in the state's Medically Needy program get some of their medical care covered by Medicare and therefore are considered "dual eligibles." They are a small segment of 6.4 million "dual eligibles" nationwide who are being switched into Part D plans.

Patient advocacy groups have been anticipating mixups in the transition, such as what happened in Florida.

"There was a major mess-up with computers," said Jeanne Finberg, an attorney and spokeswoman for the National Senior Citizens Law Center in Oakland, Calif. "(Florida) did not give that list of the Medically Needy to the federal government to enroll them."

Officials with the state chapter of the National Kidney Foundation heard the same thing.

"Not one of my Medically Needy patients got their letters," said Cathy Barnett, chairwoman of direct patient aid for the Orlando-based foundation. "I think no one knows how this (transition) is going to work."

State health-care agency spokesman Jonathan Burns disputes the state was at fault.

"Every month since May of this year, we have given (the Centers for Medicare and Medicaid) the entire population of Medicaid dual eligibles, including the Medically Needy," he said.

Getting enrolled and hoping their plans cover all of their medications is just the first obstacle for the Medically Needy, which includes 776 people in Lee County and 380 residents in Collier County who qualified in October.

Next on the list of hurdles is maintaining access to medical services that usually are paid for by Medicaid on a month-by-month basis. Some of the Medically Needy could lose their Medicaid coverage.

"Everybody is contemplating what is going to happen," said Mary Ellen Ross, executive director of the Florida Transplant Survivors Coalition in Delray Beach.

State Sen. Burt Saunders, R-Naples, chairman of Health and Human Services appropriations committee in the Legislature and who has helped save the Medically Needy program from elimination in years past, couldn't be reached for comment.

The Medically Needy program in Florida is intended to be short-term help for people who faced a sudden illness and who have no resources to pay for their medical care. By another blow of misfortune, they make a few dollars or a few hundred dollars more than what's allowed to qualify for Medicaid.

Many of the individuals in the program faced organ failure and are on dialysis, or had organ transplants and have a long list of medications they must take.

They must qualify for the coverage every month based on an income and a medical expenses formula called "share of cost."

When an accumulation of medical bills would eat up the lion's share of their monthly income, they will have incurred their "share of cost" so Medicaid covers their medical expenses for the rest of the month.

Social workers at dialysis centers, at organ transplant centers and elsewhere in the health-care system help this group. They arrange for their patients to get a month's supply of medications at the beginning of each month using specialty mail-out pharmacies. The lump sum bill reaches or surpasses the patient's share of cost, so Medicaid pays for the prescriptions and other medical expenses for the rest of the month. The cycle gets repeated every month.

To these seriously ill and often poorly educated patients, they can't navigate the system and would be lost if it weren't for the case managers who help them qualify each month, said Sarah Knott, area manager of four dialysis centers in Collier and Lee counties owned by Fresenius Medical Care.

Worse, state lawmakers in recent years have targeted the Medically Needy program for elimination but it gets salvaged in the final days of the legislative session.

"That just terrifies them," she said.

Starting in January, when the Medically Needy get enrolled in Medicare Part D plans, what's expected is they have to find a new way to meet their share of cost each month to continue qualifying for Medicaid, Knott said.

That's because their Medicare drug plan will be paying for covered medications instead of Medicaid. Due to an unrelated federal law, dialysis is covered by Medicare, she said.

One possibility is for these patients to meet their share of cost by bundling doctor appointments in the beginning of the month. Still, that may not cut it, she said.

"If it doesn't meet share of cost, they will be responsible for all those charges," Knott said. "Bottom line is they will lose ongoing medical care that Medicaid had been paying. The state has not come up with an answer."

A sure-fire way a person can meet his or her share of cost is by one hospital admission, she said, but that's not an appropriate use of the hospital system.

Ross, of the transplant survivors coalition, said she doesn't believe bundling doctors' appointments would do the trick for herself and other Medically Needy patients. She's angry the state has done nothing to address their predicament.

"We are the people who are going to be smashed by this and there is absolutely no help," Ross said. "The safety net the state has provided is evaporating."

Ray Muraida, senior human services specialist with the state Department of Children and Families in Southwest Florida, acknowledges the arrival of Part D will mean changes for the Medically Needy and whether they maintain coverage.

"It's a big shift in how share of cost is met," he said. "A lot may have gotten Medically Needy (coverage) just for medications."

Barnett, of the state kidney foundation, describes what will happen as a "big hole."

"What are we going to with the people who are dependent on the system until the glitches get worked out?" she said. "I guess we will find out Jan. 2."

Finberg of the national senior citizens law center said: "It's a whole new landscape. In that landscape there will be a tremendous amount of confusion."

Some patient advocates have heard that the state health-care agency is going to allow anyone who qualified for Medically Needy any month late this year to be covered for an entire year, rather than having re-qualify every month.

Barnett is among those who heard that but said she won't believe it until she sees something in writing.

Burns, the state agency spokesman, wouldn't comment directly on the issue.

"We are committed to working toward quality health care for Floridians and (the agency) is looking at ways this new drug benefit impacts the Florida Medically Needy program, as well as Medicaid in general," he said in a statement.

An attorney with Florida Legal Services in Miami has a different take on looming changes for the Medically Needy and others not tied to Part D.

The state Legislature during the 2005 session decided to eliminate Medicaid services to some people, depending on income, who are eligible for Medicare, Miriam Harmatz said.

Instead they will be covered under Medicare. That will have an impact on many of the Medically Needy.

"Because most Medically Needy are eligible for Medicare, they won't be eligible for continued care under Medicaid because of the legislative change," she said.

That change is supposed to take effect in January.

Burns, with the state agency, said that's not the case for the Medically Needy, who are their own category in the state Medicaid program.

What the Legislature did applies to dual eligibles in the Medicaid Aged and Disabled program who aren't in an institution, like a hospice, he said. Those individuals will no longer be covered by Medicaid but will get coverage through Medicare.

The Medically Needy will still have to meet their share of cost for ongoing Medicaid coverage after Part D starts, he said.

Confusion over the impact of Part D and the state's ongoing changes to the Medicaid system is infuriating, said Ross, with the transplant survivors group.

"Right now we are not getting exact information (from the state)," she said, adding that the Medically Needy have always been "in the squeeze" between state and federal governments.

Howard, the Naples dialysis patient, doesn't understand what's happening.

"I'm on 20 to 30 medications each day," he said, adding that the staff members at the dialysis center have always taken care of everything for him.

At the moment, the Medically Needy are just trying to survive the transition into Part D and finding prescription plans that cover all their medications, Ross said. They are turning to their pharmacists for help in selecting the right plan but pharmacists don't have all the answers.

"The transition will be unbelievable for Medically Needy in Part D," she said. "It will be such a crazed state come January."

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