State Responses to Medicare Part D
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Transcript of State Responses to Medicare Part D
State Responses to Medicare Part DPresented by:
Kimberley Fox,
Senior Policy Analyst,
Institute for Health Policy
Academy Health Annual Research Meeting
Seattle, WA
June 2006
6/27/06 Muskie School of Public Service
Survey Methods
Funded by the National Pharmaceutical Council Literature and document review Fall 2005 survey w/ telephone follow-up
Snapshot of states’ plans for adapting programs to MMA 24 existing SPAP programs 14 Medicaid agencies (representing 66% of Medicaid drug
spend), 11 in states with SPAPs. Response rate: @96% Findings reflect responses at time of survey completion.
6/27/06 Muskie School of Public Service
State Responsibilities/Options Under Part D Medicaid
Assist w/ transitioning duals Clawback payments LIS application and MSP screening responsibilities. May fill Part D gaps with state-only dollars
State Pharmacy Assistance Programs (SPAP) May fill Part D gaps Qualified SPAP expenditures count toward TROOP Part D plans must coordinate Transitional grant funding available
6/27/06 Muskie School of Public Service
Key Differences between Part D and State Pharmacy CoverageMedicaid
May face higher copayments Loss of guaranteed access if they can’t afford copayments No coverage of excluded drugs under Part D Formularies may not include drugs covered under Medicaid Loss of coverage of denied drugs during appeal More limited pharmacy networks.
State Pharmacy Assistance Programs (SPAPs) Tighter formularies/ more limited pharmacy networks LIS eligible – potentially lower cost-sharing Non-LIS eligible –
Up-front costs such as premiums and deductibles previously not required in many programs
Higher cost-sharing before and in the donut hole (varies by state).
6/27/06 Muskie School of Public Service
Part D Transitional Enrollment Issues for SPAP Enrollees and Duals Duals
Medicaid drug coverage ends Jan 2006 All duals ‘deemed eligible’ for low income subsidies Randomly assigned to below benchmark PDPs by CMS – Nov 2005 State Medicaid agencies can conduct formulary matches to recommend
more appropriate plans.
SPAP Enrollees Most not deemed eligible for LIS, must apply (exc. MSPs) All enrollees must voluntarily enroll in PDP/MA-PD Qualified SPAPs cannot auto-enroll enrollees into a preferred plan Various options to ‘facilitate’ LIS application/Part D enrollment
6/27/06 Muskie School of Public Service
SPAP and Medicaid Part D Gap-filling Options Medicaid
Premium assistance above LIS benchmark Copayments Off-formulary/PDP denied drugs or during appeals Non-Part D covered drugs (eligible for FFP)
SPAP Premium assistance (LIS or full premium) Wrap around full/partial LIS or non-LIS out-of-pocket costs
Deductibles, copayments, donut hole, Off-formulary/PDP denied drugs or out-of-network pharmacies Non-Part D covered drugs
6/27/06 Muskie School of Public Service
Filling Part D Gaps for Duals: Selected Medicaid Plans 2006
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
NY
NJ
NJ
NY,NJ
NY
NJ
NY,NJ
NJ
0 2 4 6 8 10 12 14
Part D Excluded Drugs
Drugs during appeal
Drugs Denied by PDP
Part D Copays
Premiums Above LIS
# of States
Source: Part D Survey of Medicaid and SPAP Directors, Fall 2005
Source:
N=14
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Medicaid Transition Plans for Part D Enrollment, 2005
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
4
3
5
13
13
0 2 4 6 8 10 12 14
Screening Applicationssent to SSA for MSP
3 Mo. Supply in Dec
Info to Duals on FormularyMatch
Collaborating w / RelatedAgencies
Educating Providers
# of StatesSource: Part D Survey of Medicaid and SPAP Directors, Fall 2005
6/27/06 Muskie School of Public Service
SPAP Plans Once Part D Begins, 2006
1
1
5
17
0 5 10 15 20
Maintaining Medicaidwaiver
Closing to MedicareEligibles*
Program Closing
Maintaining SomeCoverage
# of States
Source: Part D survey of SPAP and Medicaid Directors, Fall 2005.*Maryland is also closing its waiver program to Medicare eligible but will continue a second state-only program to provide wrap assistance for non-LIS eligible persons.
N=24
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Specific Part D Gaps Filled by SPAPs, 2006
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
3
10
4
5
14
11
13
4
12
0 5 10 15
Out of Netw ork
Non-Part D Covered
Appeal for Bene
Formulary
Donut Hole
Copayment
Deductible
Late Penalty
Premium
# of States
Source: Part D Survey of Medicaid and SPAP Directors, Fall 2005
N=17
6/27/06 Muskie School of Public Service
More than Half of SPAP Enrollees Will Not Qualify for Full LIS*
N=26 programs/23 states
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
44%
13%
43%
<135% FPL
135-150% FPL
>150%FPL
*Percentages based on estimates by state officials from income data, generally do not include assets.
6/27/06 Muskie School of Public Service
SPAP Efforts to Enroll Members in LIS, 2005
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
*For LIS and/or Part D Enrollment
4
5
12
9
14
0 5 10 15
State w ill Appeal LIS
Plans to Collect Assets/submit applicationsfor enrollees
Help w / Completing LIS application
LIS Authorized Rep
Mandating LIS
# of StatesSource: Part D Survey of Medicaid and SPAP Directors, Fall 2005
N=17
6/27/06 Muskie School of Public Service
SPAP Efforts to Enroll Members in Part D Plans, 2005
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
*For LIS and/or Part D Enrollment
N=17
5
5
6
11
14
0 5 10 15
Intelligent RandomAssignment
Random Assignment
Co-branding
Authorized Rep forPart D enrollment
Mandate Part D
# of StatesSource: Part D Survey of Medicaid and SPAP Directors, Fall 2005
6/27/06 Muskie School of Public Service
Few States Expanding SPAPs to New Groups
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
0
5
10
15
Excluding LISeligible
Expanding IncomeEligibility
Expanding toDisabled
Including Duals
# of
Sta
tes
N=17 states
Source: Fox and Schofield, Medicaid and SPAP Part D Survey, Fall 2005
6/27/06 Muskie School of Public Service
Summary of State Actions Short-term emergency coverage (Medicaid/ some
SPAPs) Medicaid largely not filling Part D gaps for duals over
time, except Part D excluded drugs. SPAPs holding existing enrollees harmless, but not
expanding benefits/eligibility Only a few states starting new SPAPs
States generally exercising caution… wait and see approach.
6/27/06 Muskie School of Public Service
Policy Implications/ Discussion Differences in State D-Gap plans for duals and SPAP enrollees
Larger cost-sharing differences for non-LIS SPAP enrollees relative to prior coverage than for duals.
Large potential savings to SPAP as secondary payer; little savings and potential short-term losses from the clawback for Medicaid.
Formularies – to wrap or not to wrap. Don’t want to encourage Part D plans to limit formularies to narrowest possible
standard Adverse effects from reduced drug coverage as a result of restricted formularies may
result in more cost to the state if that leads to use of more expensive medical services. States may want to reserve the right to cover in limited circumstances where likelihood
of adverse events is higher. At minimum, could help duals appeal. Reconsideration of federal match (?)
SPAPs Can Do More to Maximize SPAP Savings allowing them to potentially fill more gaps or expand eligibility.
Monitor state coverage decisions on duals and SPAP enrollees.
6/27/06 Muskie School of Public Service
Further Information
For copies of this presentation: [email protected]
Full report of survey findings available at:
http://muskie.usm.maine.edu/m_view_publication.jsp?id=3409