Transcript SPAP - AcademyHealth

State Responses to Medicare Part D
Presented by:
Kimberley Fox,
Senior Policy Analyst,
Institute for Health Policy
Academy Health Annual Research Meeting
Seattle, WA
June 2006
Survey Methods
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Funded by the National Pharmaceutical Council
Literature and document review
Fall 2005 survey w/ telephone follow-up
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6/27/06
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.
Muskie School of Public Service
State Responsibilities/Options Under Part D
Medicaid
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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)
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6/27/06
May fill Part D gaps
Qualified SPAP expenditures count toward TROOP
Part D plans must coordinate
Transitional grant funding available
Muskie School of Public Service
Key Differences between Part D and
State Pharmacy Coverage
Medicaid
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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)
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Tighter formularies/ more limited pharmacy networks
LIS eligible – potentially lower cost-sharing
Non-LIS eligible –
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6/27/06
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).
Muskie School of Public Service
Part D Transitional Enrollment Issues for
SPAP Enrollees and Duals
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Duals
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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
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6/27/06
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
Muskie School of Public Service
SPAP and Medicaid Part D Gap-filling
Options
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Medicaid
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Premium assistance above LIS benchmark
Copayments
Off-formulary/PDP denied drugs or during appeals
Non-Part D covered drugs (eligible for FFP)
SPAP
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6/27/06
Premium assistance (LIS or full premium)
Wrap around full/partial LIS or non-LIS out-of-pocket costs
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Deductibles, copayments, donut hole,
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Off-formulary/PDP denied drugs or out-of-network pharmacies
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Non-Part D covered drugs
Muskie School of Public Service
Filling Part D Gaps for Duals:
Selected Medicaid Plans 2006
N=14
NY
NY
Premiums Above LIS
NJ
NJ
Part D Copays
NY,NJ
NY,NJ
Drugs Denied by PDP
Source:
NJ NJ
Drugs during appeal
Part D Excluded Drugs
0
2
4
6
8
10
# of States
Source: Part D Survey of Medicaid and SPAP Directors, Fall 2005
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
6/27/06
Muskie School of Public Service
12
14
Medicaid Transition Plans for Part D
Enrollment, 2005
Educating Providers
13
Collaborating w / Related
Agencies
13
Info to Duals on Formulary
Match
5
3
3 Mo. Supply in Dec
Screening Applications
sent to SSA for MSP
4
0
2
4
6
8
# of States
Source:
SPAPDirectors,
Directors,Fall
Fall2005.
2005
Source:Part
PartD DSurvey
SurveyofofMedicaid
SPAP andand
Medicaid
6/27/06
Muskie School of Public Service
10
12
14
SPAP Plans Once Part D Begins, 2006
N=24
Maintaining Some
Coverage
17
5
Program Closing
Closing to Medicare
Eligibles*
1
Maintaining Medicaid
waiver
1
0
5
10
15
20
# 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.
6/27/06
Muskie School of Public Service
Specific Part D Gaps Filled by SPAPs, 2006
N=17
12
Premium
4
Late Penalty
13
Deductible
11
Copayment
14
Donut Hole
5
Formulary
4
Appeal for Bene
10
Non-Part D Covered
3
Out of Netw ork
0
5
10
# of States
Source: Part D Survey of Medicaid and SPAP Directors, Fall 2005
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
6/27/06
Muskie School of Public Service
15
More than Half of SPAP Enrollees Will
Not Qualify for Full LIS*
N=26 programs/23 states
<135% FPL
135-150% FPL
43%
44%
>150%FPL
*Percentages based on estimates by state
officials from income data, generally do not
include assets.
13%
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
6/27/06
Muskie School of Public Service
SPAP Efforts to Enroll Members in LIS,
2005
N=17
14
Mandating LIS
9
LIS Authorized Rep
12
Help w / Completing LIS application
Plans to Collect Assets/submit applications
for enrollees
5
4
State w ill Appeal LIS
0
5
10
# of States
*For LIS and/or Part D Enrollment
Source:
Part D
SPAPDirectors,
Directors,Fall
Fall
2005
Source: Part
D Survey
Survey of
of Medicaid
SPAP andand
Medicaid
2005.
6/27/06
Muskie School of Public Service
15
SPAP Efforts to Enroll Members in Part D
Plans, 2005
N=17
14
Mandate Part D
Authorized Rep for
Part D enrollment
11
6
Co-branding
Random Assignment
Intelligent Random
Assignment
5
5
0
5
10
*For LIS and/or Part D Enrollment
# of States
Source: Part D Survey of SPAP and Medicaid Directors,
Fall 2005.
Source: Part D Survey of Medicaid and SPAP Directors, Fall 2005
6/27/06
Muskie School of Public Service
15
Few States Expanding SPAPs to New
Groups
N=17 states
# of States
15
10
5
0
Excluding LIS
eligible
Expanding Income
Eligibility
Expanding to
Disabled
Source: Fox and Schofield, Medicaid and SPAP Part D Survey, Fall 2005
Source: Part D Survey of SPAP and Medicaid Directors, Fall 2005.
6/27/06
Muskie School of Public Service
Including Duals
Summary of State Actions
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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
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Differences in State D-Gap plans for duals and SPAP enrollees
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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 shortterm losses from the clawback for Medicaid.
Formularies – to wrap or not to wrap.
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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 (?)
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SPAPs Can Do More to Maximize SPAP Savings allowing them to potentially fill
more gaps or expand eligibility.
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Monitor state coverage decisions on duals and SPAP enrollees.
6/27/06
Muskie School of Public Service
Further Information
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For copies of this presentation:
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[email protected]
Full report of survey findings available at:
http://muskie.usm.maine.edu/m_view_publication.js
p?id=3409
6/27/06
Muskie School of Public Service