Transcript Medicare Part D

Medicaid: A Brief Overview and Case
Studies on Access to Prescription
Drugs
Miriam Harmatz
Florida Legal Services
February 25, 2009
Medicaid Eligibility
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Need categorical connection
- Aged or disabled
- Child or parent
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Low income
- Parent with child: income must be below
$682 and assets less than $2,000
- Aged, blind or disabled: income must be below $657
assets less than $2,000
Medicaid Structure
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Federal/State funding
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State flexibility but federal law controls
42 U.S.C. § 1396 et seq.
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Entitlement*
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Complicated
Prescription Drug Benefit
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$$$: huge budget item, with costs rising more
quickly than other benefits
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Prior authorization: tool for controlling costs
required for certain brand name drugs and
drugs not on PDL
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Result: patients did not get their meds
Due Process for Prescription Denials
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Hernandez et al. v. Medows, 209 F.R.D. 665 (S.D. Fla 2002.)
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Medicaid statute
42 U.S.C. § 1396a(a)(3)
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Goldberg v. Kelly
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Medicaid regulations
42 C.F.R. § 431.200 et seq.
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14th Amendment
Importance of data, experts and
settlement
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Discovery regarding drug denials
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Relationship to class and permanent
injunction
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Complexity of benefit: settlement best
outcome
What drugs can be prescribed?
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On label
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Off label
Medically accepted indication
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42 U.S.C. § 1396r-8(k)(6)
The term “medically accepted indication” means any
use for a covered outpatient drug which is approved
under the Federal Food, Drug, and Cosmetic Act [21
U.S.C.A. § 301 et. Seq.], or the use of which is
supported by one or more citations included or
approved for inclusion in any of the compendia
described in subsection (g)(1)(b)(i) of this section.
Compendia
Applies to Medicaid & Medicare Part D
Edmonds et al. v. Levine
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Off label marketing abuses
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State response
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Adverse impact on recipients
Structure of prescription benefit
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Rebates
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Very limited grounds for denial
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Role of Compendia
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Can PA
Medicaid Reform
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Goal to block grant/privatize
Defined benefit/predictable spending
Plans determine amount, duration, and
scope
PD limits on #
Lack of data regarding denials
Medicare Part D
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Privatized model
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Limited government role
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Lack of denial data or info on price
negotiations
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Lack of uniform PDL structure
“Medically Needy” hurt by Part D
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Categorical connection: Aged or disabled
– over income or over assets; share of cost (SOC) like
deductible
Before Part D those with high drug costs met SOC
– Full Medicaid-including drug benefit/no co-payments
– Full Medicare cost share benefit deductible, co-insurance,
co payments
After Part D
– Lost Medicaid
– Huge Part D co-payments
– No Medicare cost sharing benefit
Medicare Part D “Victim”
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RB needs transplant
Income $1200/month, plus Medicare
Medically needy share of cost (SOC) $ 900
Transplant drugs Part B: $ 700
All other drugs covered by Part D
Cannot meet Share of cost; or afford cost of
Part B drugs
Rejected for evaluation
Is health care right or responsibility?
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If right- for everyone or just the “categorically
connected” poor?
If right for everyone, cover every medically
necessary service?
Government v. private sector?