Title: The Pharmacy Safety Net and Medicare Part D
1The Pharmacy Safety Net and Medicare Part D
- Presented by
- Kimberley Fox,
- Institute for Health Policy
- October 23, 2006
2State Survey - Methods
- Funded by the National Pharmaceutical Council
- Medicaid/SPAP Fall 2005 survey
- 24 existing SPAP programs
- 14 Medicaid agencies (representing 66 of
Medicaid drug spend), 11 in states with SPAPs. - Response rate _at_96
- Follow-up survey of all SPAPs in Summer/Fall
2006. - 19 out of 20 SPAPs responded
- Findings reflect responses at time of survey
completion.
3Key Differences between Part D and Previous State
Pharmacy Benefits
- Medicaid
- May face higher copayments
- Loss of guaranteed access if they cant afford
copayments - No coverage of excluded Part D drugs offered by
many Medicaid programs - Formularies may not include drugs covered under
Medicaid - Loss of coverage of denied drugs during appeal.
- More limited pharmacy networks
- State Pharmacy Assistance Programs (SPAP)
- Different cost-sharing - Varies for LIS/ non-LIS
eligible - Formularies may not include drugs covered under
SPAP - More limited pharmacy networks
- No coverage of excluded Part D drugs.
-
4Potential Safety Net Role for States in Part D
- Medicaid
- May assist duals in getting into plans that best
meet their needs - With state-only s cover differences in
cost-sharing including - Premium assistance above LIS benchmark
- Copayments
- Cover excluded drugs (federally required if
Medicaid covers for non-duals) eligible for
federal matching s. - Cover off-formulary/PDP denied drugs or during
appeals. -
5Potential Safety Net Role for States in Part D
- State Pharmacy Assistance Programs (SPAP)
- May assist SPAP enrollees in getting into plans
that best meet their needs and applying for
low-income subsidies. - Can contribute toward Part D gaps
- Premium assistance (LIS or full premium)
- Cost sharing - Deductibles, copayments, donut
hole (TROOP) - Off-formulary/PDP denied drugs or out-of network
pharmacies - Part D excluded drugs
- If SPAP conforms to federal rules, state
cost-sharing contributions can count toward
enrollees true out-of-pocket costs (TROOP). -
6Medicaid Fall 2005 Survey Results
- Generally not wrapping-around Part D for the
dual-eligibles (exc. Part D excluded drugs). - Not assisting with assignment to Part D plans
beyond CMS random assignment. (ex. Maine) - No plans to offer short-term emergency drug
supply, but in Jan 2006, most Medicaid programs
did provide short-term emergency coverage due to
significant problems during the transition.
7Filling Part D Gaps for Duals Selected Medicaid
Plans 2006
NY
NY
NJ
NJ
NY,NJ
NY,NJ
NJ
NJ
Source Part D Survey of SPAP and Medicaid
Directors, Fall 2005.
8SPAP Fall 2005 Survey Results
- Most SPAPs maintaining coverage to hold enrollees
harmless. - Most SPAPs mandating enrollment in Part D plans
and application for LIS to be eligible for SPAP
but many not taking active role. - Considerable variation in what states are
electing to supplement under Part D. - SPAP savings expected, but level of saving
unclear. - Few states expanding eligibility.
9SPAP Plans Once Part D Begins
10Few States Expanding SPAPs to New Groups
Source Part D Survey of SPAP and Medicaid
Directors, Fall 2005.
11Specific Part D Gaps Filled by SPAPs
Source Part D Survey of SPAP and Medicaid
Directors, Fall 2005.
12Part D Excluded Drugs Covered by SPAPs, 2006
13SPAP Efforts to Enroll Members in Part D Plans
N17
For LIS and/or Part D Enrollment
Source Part D Survey of SPAP and Medicaid
Directors, Fall 2005.
14SPAP Efforts to Enroll Members in LIS
N17
For LIS and/or Part D Enrollment
Source Part D Survey of SPAP and Medicaid
Directors, Fall 2005.
15Anticipated SPAP Low Income Subsidy Eligible
Based on Income, 2005
16Actual SPAP Low Income Subsidy Eligible, 2006
17Summary of State Actions
- States generally exercising caution wait and see
approach. - Short-term emergency coverage (Medicaid/ some
SPAPs) - Medicaid largely not filling Part D gaps for
duals beyond transition, except Part D excluded
drugs. - SPAPs holding existing enrollees harmless, but
not expanding benefits/eligibility - Only a few states starting new SPAPs
18Part D State Best Practices
- Medicaid
- Cover off-formulary if medically necessary (NJ,
NY) - Assigning duals based on drug history. (ME)
- Holding duals harmless to existing Medicaid
copayments. - Eliminating MSP asset test to get more LIS deemed
eligible (ME,VT) - SPAPs
- Maximizing fedl s by getting more enrollees
into LIS - Interventions to improve plan fit
- Assigning to plans based on drug history (e.g.
NJ, ME, etc) - conduct cost/benefit of paying non-LIS premiums
(VT, CT) - Using SPAP savings to fill other gaps
- Asset ineligible LIS Up to 200 FPL disabled
(NV) - Expand benefits to other rx uninsured non-elderly
(e.g. WY/MD) - Starting a new SPAPs (HI, MT) good return on
investment
19Discussion/ Policy Implications
- Duals
- Getting in a plan that covers most drugs is
important if most states not providing safety net
coverage for off-formulary. - Potential reduction in compliance/adherence to
necessary drugs. - Even relatively modest increases in cost-sharing
could reduce access. - More administrative hurdles to overcome.
- Need for research to assess adverse health impact
of Part D on duals with and without state
supplementation. - SPAPs
- More protection extended to hold these people
harmless - Bigger marginal impact than duals
- Need to move toward greater simplification of
coordination w/ Part D and LIS to maximize use of
state dollars. - Federal govt needs to clarify policy on working
w/ preferred plans. Several states appear to be
doing and more could benefit from reduced
administrative costs of working with a limited
of plans - If not, focus on better plan fit/ paying higher
than benchmark premiums where appropriate. - Monitor impact of SPAP off-formulary coverage in
states that are covering.
20Further Information
- For copies of this presentation
- kfox_at_usm.maine.edu
- Full report of Fall 2005 survey findings
available at - http//muskie.usm.maine.edu/m_view_publication.jsp
?id3409